An Exercise in Casting Cares

New day breaking over Balestrand, on the northern shore of the Sognefjord, west coast of Norway; photo BJ Gabrielsen.

In Psalm 55:16-17, King David says “As for me, I shall call upon God, and the Lord will save me. Evening, morning and at noon, I will complain and murmur, and He will hear my voice.” God’s ears are open to our cries and His shoulders are wide enough to carry our burdens. He is sovereign over the universe, so He is certainly capable of working out our problems and meeting our needs. I recently read an exercise that helped make casting my cares on Him a practical act.

First, take a piece of paper and write down the things that cause your anxiety. For me, as a 77- year old prostate cancer patient, my first item was that my cancer continue to be controlled, and that I not die of this disease. Upon further thought, there were other items that were cheating me out of peace but I will focus on the cancer here.

Next, pray each issue into God’s care. For me, praying the words of Romans 12:1, and inserting my own name as follows, is a daily act. “I urge you therefore” ____(your name), “by the mercies of God, to present your (my) body, a living and holy sacrifice, acceptable to God, which is my spiritual” (some versions say rational) “service of worship.”

Finally, as you pray, visualize placing the situation into God’s omnipotent hands. Imagine handing our bodies over to the Lord, while saying, “Father, I give you my disease or condition. You are more than sufficient to handle it, and I trust You to guide me.”

Some people may resist this suggestion because certain pseudo-spiritual movements have a method they call visualizing. But above, the term refers to the beautiful word pictures throughout the Bible, which God intended to help us understand our relationship to Him. This type of visualizing creates a mental snapshot of God doing just what He says He’ll do in  Psalm 55:22, “cast your burden upon the Lord and He will sustain you. He will never allow the righteous to be shaken.” He also says “do not be anxious for your life as to what you shall eat, or what you shall drink, nor for your body.” (Matthew 6:25).

When you have transferred all your worries to God’s hands, wad up the paper and then destroy it. In doing so, you symbolize the transaction that just took place. Your cares are no longer yours – every one of them belongs to the Lord. Then walk away in perfect peace.

If you are not sure whether you have such a personal relationship with God, see the following.

Much of the post above, was published in the January 5th, 2019 In Touch devotional, written by Dr. Charles Stanley.

Please circulate to any interested men; and, some urological humor.

This post is a bit out of the ordinary but I first want to thank all of you who read this website. As many of you know, anyone can subscribe to automatically receive the blogs by e mail as they are posted by entering an e mail address on the right side of the home page. The posts cover a wide variety of prostate issues including general patient information, screening, diagnostics, genetics, imaging, and treatment at various stages. Also included are posts dealing with encouragememt from a Christian perspective which I have found useful during my own disease journey. I want to ask you faithful readers to send this blog to any men in your community who could possibly benefit from reading this site and tell them they can subscribe. Word-of-mouth is the best way to disseminate the information to as many men as possible. They can sign up and read only those posts that apply to their individual interests. Thank you in advance for doing this. 

Meanwhile, I want to share the funniest story I know dealing with urological issues. A 90-year old man goes to his urologist for a checkup. Physically, he passes with flying colors. During the exam, his urologist asks, “how are you mentally?” “Oh”, the man exclaims, “I am as sharp as a tack for my age. I remember names, dates, and hardly ever misplace anything.” “Amazing”, proclaims the urologist, “and how are you spiritually?” “I am glad you asked”, the man confidently responds. “God and I are like that”, he said crossing his fingers. “We are tight. In fact, I’ll give you an example. At night, when I get up to go to the bathroom, a surreal glow guides my path. Upon finishing and returning to bed, the surreal glow dissipates”. The urologist listens intently, shakes his head in amazement and at the end of the visit, he tells the man how extremely fortunate he is for his age. Several weeks go by and the urologist accidently runs into the man’s wife at a local supermarket. He greets her and says, “congratulations on your husband. Physically he is fine, he is mentally sharp and spiritually, he related to me a most unusual phenomenon. He says that when he gets up at night to use the bathroom a surreal glow guides him and when finished to return to bed, the surreal glow dissipates.”  Upon hearing this, his wife’s face droops, eyes widen, mouth opens, as she exclaims, “oh my goodness, he’s peeing in the refrigerator again.”

Six Myths About Chemotherapy for Prostate Cancer

According to Dr. William Oh,  Deputy Director of  the Tisch Cancer Institute, Chief of the Division of Hematology and Medical Oncology, and Professor of Medicine at the Icahn School of Medicine at Mount Sinai in New York, there are six myths about chemotherapy.

Some prostate cancer patients shy away from or choose not to utilize chemotherapy. Their hesitation may result from an outdated understanding of chemotherapy’s side effects and its effectiveness against prostate cancer. In this blog, Dr. Oh explores the myths driven by common misperceptions about chemotherapy and replaces them with some facts.

MYTH #1:  Chemotherapy is a last resort.

“Some patients believe that we use chemotherapy when we are out of options. Far from a last resort, there are currently promising studies utilizing chemotherapy earlier in the treatment of prostate cancer. For instance, in men with newly diagnosed metastatic disease, chemotherapy significantly improves survival.”

MYTH #2:  Chemotherapy is a single and outdated option.

“Chemotherapy is not a single drug. In fact there are many “chemotherapies”, both oral and intravenous, and new chemotherapies are being developed and approved regularly.

In prostate cancer, there have been continuous improvements over the past few years. In the past, an older drug called mitoxantrone was approved by the FDA to relieve cancer symptoms only. Then something important happened in 2004: docetaxel (taxotere) chemotherapy was shown to be the first drug to improve overall survival for men with metastatic prostate cancer that became resistant to hormone treatments. This was a critical milestone, as no drugs to that point could lengthen survival. In 2010, the FDA approved another chemotherapy drug for prostate cancer called cabazitaxel.

Far from being outdated, these advancements allow me as an oncologist to have a larger toolbox to treat cancers which adapt to different types of treatments. For instance, resistance often develops to drugs like abiraterone or enzalutamide, which target the androgen receptor.  Chemotherapy may more effectively kill those resistant cancer cells.

Finally, ongoing research will determine how best to combine chemotherapy with other drugs and radiation as well as use biomarkers to personalize treatment. We thought chemo might go away with newer treatments, but we use it as often as we did before as men are living longer and better lives with advanced prostate cancer.”

MYTH #3:  Chemotherapy has no role in an era of immunotherapy and precision medicine.

“Some people believe chemotherapy is a ‘shotgun’ approach. Patients want more targeted therapy specific to their cancer. The fact is we do have specific chemotherapy to kill prostate cancer cells called taxanes. Taxanes stop cancer cells from dividing and also may interfere with androgen receptor signaling in prostate cells as well.

In fact, when a patient stops responding to drugs such as abiraterone or enzalutamide, a blood test for a biomarker called ARV-7 predicts greater benefit from chemotherapy than to continue the androgen pathway drug. This test is now approved in the U.S.” (See a recent blog on this website describing AR-V7 testing.)

MYTH #4:  I’ll be nauseated and vomiting throughout my chemotherapy.  

“Chemotherapy induced nausea and vomiting (CINV) can be very scary and intimidating and many patients have known or heard about someone who has had it. Two things are really important to understand about CINV.

First, there are many types of chemotherapy and their ability to cause CINV varies widely.  In fact the drugs used in prostate cancer are unlikely to cause this. The American Society of Clinical Oncology (ASCO) Guidelines consider cabazitaxel, for instance, as a ‘low risk’ drug for causing CINV.

Second, modern antiemetics have revolutionized the treatment of CINV. Antiemetics are drugs used to prevent nausea and vomiting and there are a host of agents available to use. Typically I will incorporate one of these on the day of therapy and prescribe something for home, but most patients do not need it.”

MYTH #5:  I won’t be able to function day-to-day while on chemo.

“Some men believe their quality of life will drastically suffer while on chemotherapy. Fortunately, these newer drugs have much fewer side effects. The most common side effect in day-to-day life is fatigue. This is usually mild to moderate and I find that most patients are able to continue many of their regular activities. For instance, they may continue to work, spend time with family, and exercise.”

MYTH #6:  I’ll permanently lose all my hair after chemo.

“It is true that many prostate cancer patients experience temporary hair loss while undergoing chemotherapy. Some patients won’t lose their hair at all. Others will experience thinning hair.

In nearly all patients, the hair loss is reversible once chemotherapy is complete. If you experience hair loss, your hair should grow back several months following your chemotherapy treatment.”

FACT:  Chemotherapy is a key treatment in the fight against advanced prostate cancer.

“Battling prostate cancer may be the hardest fight you’ve encountered. Certainly, the side effects of some of the treatments you’ve received have been difficult. There is no question that chemotherapy comes with its own set of challenges.

However, it is critical to understand how important chemotherapies used to combat prostate cancer can be in extending and even improving your life. Many studies have shown that drugs such as docetaxel, cabazitaxel, and others can play a key role in treating metastatic prostate cancer, cancer that has spread beyond the prostate.

Please ask your oncology team about any specific concerns you may have before starting any treatment regimen. Knowledge is the most effective tool in the battle against prostate cancer.”

See the following link from Zero-the Fight to End Prostate Cancer, published Jan. 10, 2019.

Simple Blood Tests to Determine Best Treatment Options for Advanced Prostate Cancer

Blood tests that examine circulating tumor cells, CTC’s, (cells that shed from the tumor or metastasis into circulation), for the presence of a mutated AR-V7  protein, could help determine if a patient with advanced prostate cancer would fare better with chemotherapy or with medicines such as enzalutamide (Xtandi) or abiraterone (Zytiga) that target the androgen receptor (a cellular protein that binds male hormones). But as happens with many medications, tumors often develop a resistance to such therapies that target the androgen receptor. Resistance develops because the medicines target a domain of the receptor that is missing in the AR-V7 version.

When a patient is first diagnosed with metastatic hormone-resistant prostate cancer, the preferred treatment involves androgen receptor inhibitors like Xtandi or Zytiga. But if a patient fails a first-line treatment with these inhibitors, there is no guarantee he’ll respond to a second inhibitor. In such cases, researchers need biomarkers that help them select which patients should receive a second androgen receptor inhibitor, and which should switch to chemotherapy.

One international team of researchers tested whether AR-V7, measured by a blood test in circulating tumor cells  could predict the best treatment approach for each patient. The test they used, called  Oncotype DX AR-V7 CTC nuclear protein test, was developed by Epic Sciences and Genomic Health. (A similar test has been developed at Johns Hopkins University and is called CTC AR-V7 RNA test.)

In one study of 142 patients at three institutions, all had been treated with one of the androgen receptor inhibitors (Xtandi or Zytiga) without success. Seventy patients were then moved to another round of treatment with an androgen receptor inhibitor, while 72 patients were treated with taxane-based chemotherapy — Taxotere (docetaxel) or Jevtana (cabazitaxel). Patients were followed for up to 4.3 years.

As expected, researchers found that patients who were negative for AR-V7 survived significantly longer with an androgen receptor inhibitor (19.8 months) than with chemotherapy (12.8 months). Conversely, chemotherapy was a better approach for patients who were positive for AR-V7, nearly doubling survival times compared to the androgen receptor inhibitor — 14.3 vs. 7.3 months. Overall, these results suggest that assessing AR-V7 levels in circulating tumor cells through a blood test may help identify the best second-line therapy for patients with metastatic hormone-resistant prostate cancer. These results were published in an issue of  JAMA Oncology.

Meanwhile, in a second study, investigators at the Duke Cancer Institute designed a multi-center study — called PROPHECY (NCT02269982) – to evaluate how well both blood tests  above predict the effectiveness of these hormone therapies.

A total of 118 men were enrolled at five medical centers to provide external validation for the two tests. For both tests, AR-V7 detection correlated with worse progression-free survival (PFS) — the length of time during or after treatment without disease progression — and overall survival (OS). While the Johns Hopkins test appeared to be more sensitive and flagged more non-responding patients, the Epic test seemed to be more specific, leading to no false-positive data.

“We have therapies to treat recurrent, metastatic prostate cancer, but they don’t work on everyone, and cross-resistance is a major emerging problem in our field. It’s important to know who will be more likely to respond and who has little chance of benefiting in order to rapidly provide alternative, more effective therapies or to develop new therapies for these men,” said Andrew Armstrong, MD, associate director for clinical research in the Duke Prostate and Urologic Cancer Center. “Having this predictive power could spare many men from undergoing therapies that would simply not benefit them, saving time, money and a great deal of emotional distress,” Armstrong said. “The results of this study are clinically useful in guiding care, particularly in men with high-risk disease and those who have already tried enzalutamide or abiraterone.”

Both of the studies were summarized in articles published online in Prostate Cancer News Today, August 8th  and June 18th, 2018 respectively.