Category: General Patient Information

Predicting Outcomes and Characterizing Prostate Tumors.

Boca Pass toward Cayo Costa, Boca Grande, Florida. bjgabrielsen photo.
Boca Pass toward Cayo Costa, Boca Grande, Florida.
bjgabrielsen photo.

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.

Updates on Active Surveillance (AS) for Prostate Cancer.

Active Surveillance (AS) is a monitoring program with possible application for patients diagnosed with low-risk prostate cancer. It is gaining popularity as a means to avoid overtreatment of indolent, slow-growing prostate cancers. The likelihood of harboring small bits of prostate cancer in a man is about equal to his age as a percentage. For example, in men age 50-70 (the key age group for diagnosing prostate cancer), around 60 percent of men will have small bits of prostate cancer. An example of a good candidate for AS would be a man with a mildly elevated PSA (less than 10) whose biopsy shows a relatively small amount of Gleason 6 prostate cancer. During active surveillance, prostate cancer is carefully monitored for signs of progression using a PSA blood test, a digital rectal exam (DRE) and a repeat biopsy of the prostate at one year and then at specific intervals thereafter. Subsequent treatment might be initiated if symptoms develop, or if tests indicate the cancer is growing. Recently, multiparametric magnetic resonance imaging (MRI) has also emerged as a tool in monitoring patients on AS. A new retrospective study published in the Journal of Urology (and summarized in the Jan. 23, 2013 issue of the Prostate Cancer Foundation NewsPulse) looked at a group of 262 men who were placed on a program of active surveillance in order to determine the rate of disease progression and time frames the men remained on active surveillance before moving to active treatments such as surgery, radiation or cryotherapy. During the follow-up period (a median of 29 months), 16 percent of the patients in the study ultimately received active treatment for their cancers. The authors found that the two-year probability of the men to remain on active surveillance was 91 percent; at 5 years, 75 percent. This study “provides short-term evidence that for highly-select patients, AS appears to be safe, durable and associated with low but finite risk of disease progression.” Larger and longer-term studies are needed and on-going. In an important comment, study author Dr. Peter Scardino strongly urged for a “mandatory” restaging, or repeat biopsy prior to men enrolling in an AS program. The researchers base this on their finding that a repeat biopsy prior to the initiation of active surveillance deceased the percentage of men deemed to be low-risk by approximately 30 percent.

Another very interesting review article on AS has also been published in the Feb. 2013 issue of the Prostate Cancer Research Institute (PCRI) insights. One specific note from this article describes on-going research on the effects of capsaicin, the micro nutrient found in hot chili peppers. There is a specific receptor (TRPV-6) for capsaicin in prostate cancer cells which when activated results in inhibition of cell proliferation and invasion. Studies are on-going in mice and humans. The same review of active surveillance also describes a method of specifically killing prostate cancer cells in men using MRI-guided thermal ablation (targeted ultrasound waves which are converted to heat in the prostate tissue).

Finally, it should be noted that the terms “active surveillance” and “watchful waiting” differ as applied to prostate cancer. AS is a disease management strategy that delays curative treatment until it is warranted based on defined indicators of disease progression. In contrast, the strategy of “watchful waiting” foregoes curative treatment and initiates intervention only when symptoms arise.

 

Weekly Consumption of Deep-Fried Foods Linked to Prostate Cancer.

I don’t usually write about the implications of diet on prostate cancer. But a former scientific colleague recently sent me an article from Genetic Engineering and Biotechnology News which cited research findings from the well-respected Fred Hutchinson Cancer Research Center. Researchers there found that men who reported eating French fries, fried chicken, fried fish, and/or doughnuts at least once a week had an increased risk of prostate cancer that ranged from 30–37% as compared to men who said they ate such foods less than once a month. Weekly consumption of these foods was also associated with a slightly greater risk of more aggressive prostate cancer. The effect also appears to be slightly stronger with regard to more aggressive forms of the disease defined by elevated PSA levels or Gleason scores. “For the study, the investigators analyzed data from two prior population-based case-control studies involving a total of 1,549 men diagnosed with prostate cancer and 1,492 age-matched healthy controls. The men were Caucasian and African-American Seattle-area residents and ranged in age from 35 to 74 years.”  Further explanation is provided in the linked article. It may be that “we are what we eat.”

Prostate Cancer Information from Johns Hopkins Urology.

There are numerous excellent medical research institutions and hospitals which specialize in the diagnosis and treatment of prostate cancer. I can speak first-hand about one of them, namely Johns Hopkins in Baltimore, MD. Each year, the U.S. News and World Report magazine ranks medical institutions according to their specialty and for the past fifteen years at least, Johns Hopkins Urology has been ranked #1. I can also personally attest to their expertise, care and knowledge since I have had successful surgeries at Hopkins as far back as the 1990’s. Hopkins publishes their Johns Hopkins Health Alerts covering a multitude of disciplines including urology and prostate cancer. To any man who has questions about prostate health and cancer, I would recommend their reference entitled “Choosing the Right Treatment for your Prostate Cancer.” I can personally recommend the knowledge and expertise of the chief author, Dr. Jacek Mostwin as well as his colleagues, among them Dr. H. Ballentine Carter.

In addition to commercial materials as described above, Johns Hopkins also publishes their Prostate Disorders Health Alerts to which one can subscribe electronically. Their recent December 19th, 2012 issue described four (4) categories of prostate cancer risk as defined by the National Comprehensive Cancer Network. These categories range from very low risk, to low, intermediate and high risk. The categories are based upon the stage of the cancer, prostate-specific antigen (PSA) and PSA density values, Gleason scores and the percentage of cancerous prostate cores as detected by biopsies. Guidelines for possible management scenarios are also provided for the four classification categories. The December 13th, 2012 issue of the Hopkins Prostate Disorders Health Alert describes four (4) common misconceptions about prostate cancer. These misconceptions are related to “normal” PSA values and the presence or absence of prostate cancer and potential negative side effects of prostate biopsies including the spread of the cancer and erectile dysfunction.

Androgen-deprivation (hormone therapy) for advanced prostate cancer is accompanied by several risks, among them osteoporosis and loss of bone mineral density which may result in fractures. For such men, Johns Hopkins (in their January 3rd, 2013 Health Alert) recommends annual bone-density scanning with dual-energy X-ray absorptiometry (DEXA scanning). If osteoporosis is indicated, treatment with bisphosphonates (such as Fosamax or Reclast) or a new drug that blocks the formation of a protein that causes bone to break down (Prolia) may be prescribed.

Newly Diagnosed Prostate Cancer; What You Need to Know.

An extremely useful article was recently published by Nathan Roundy in the August, 2012 issue of the Prostate Cancer Research Institute (PCRI) Insights. The article is directed toward men who have been recently diagnosed with prostate cancer. It defines various medical terms and diagnostic and treatment details. Risk assessment tools are provided to help one determine whether the cancer is of low, intermediate or high risk. These tools include brief discussions (with website references) of risk stratification methods as published by Dr. Anthony D’Amico in 1998; a schematic prostate cancer guideline summary published by the National Comprehensive Cancer Network; the CAPRA risk score based on statistical outcomes from over 10,000 men; and, the PCRI SHADES risk tool. An extremely useful Risk Analysis Data Form is also included (and can be downloaded). This form contains a series of fourteen questions and related medical information to be provided during visits with one’s urologist. This article is an excellent initial reference for anyone newly diagnosed with prostate cancer. The document is only intended to assist the prostate cancer patient to understand their diagnosis and to outline questions and issues to be discussed with one’s urologist. It should never be considered as actual medical advice.

The PCRI Insights are published quarterly and comprise highly-recommended reading for any prostate cancer patient. The August 2012 issue also features a patient’s experience with the process of active surveillance of his cancer.

Active Surveillance May Be the Preferred Option in Some Men with Prostate Cancer.

A recent study from Johns Hopkins University School of Medicine published in the Journal of Clinical Oncology concluded that for men over 65 “active surveillance is the first option for men in this category with very-low-risk disease” according to senior investigator Dr. H. Ballantine Carter. The initial question for such patients should be “whether any therapy is appropriate for them, not which therapy.” The clinical definition of “very-low-risk prostate cancer is provided in the article initially published in the April 19th, 2011 issue of the National Cancer Institute (NCI) Cancer Bulletin.  At Johns Hopkins, the active surveillance program involves a semi-annual check up and an annual biopsy. Among the 769 men enrolled in the Hopkins active surveillance program from 1995-2010, approximately 80% had very-low-risk disease as defined by their Gleason score and other factors listed. Overall, 41% of the men in this study did not require any form of treatment even after ten years of follow-up, providing evidence that “active surveillance” is safe. For additional information, see the July 24th, 2012 issue of the NCI Cancer Bulletin.

A Vitamin D – Prostate Cancer Connection and Other News.

There has been much discussion concerning the role of blood vitamin D levels and its metabolism and their relationship to prostate cancer. A study examining this relationship published in the April 12th issue of the Journal of the National Cancer Institute found that men with the highest plasma levels of vitamin D “were 57% less likely to develop a lethal form of the disease.”  Plasma vitamin D levels and common variation among several vitamin D-related genes associated with its metabolism were associated with lethal prostate cancer risk, suggesting that vitamin D is relevant for lethal prostate cancer. However, vitamin D levels did not affect the chances of developing prostate cancer. It should be noted that vitamin D levels were determined by the 25-hydroxyvitamin D assay and not the 1,25-dihydroxy assay. One can attain sufficient vitamin D levels from foods, D3 supplements of varying strengths (units) as well as from calcium citrate or calcium carbonate supplements which also contain vitamin D. It is strongly recommended that the amount (units) of vitamin D required to maintain an optimal blood level should be determined in consultation with a physician as highly excessive amounts may be harmful. Optimal serum levels of vitamin D are 20-50 ng/mL in the USA according to some sources while others recommend 50-80 ng/mL. (International levels are 50-125 nMol/L.)  A summary of this research appeared in the April 27th, 2012 issue of the Prostate Cancer Foundation NewsPulse. In addition to this study, this issue of NewsPulse also contained articles dealing with High-Intensity Focused Ultrasound (HIFU) treatments and proton beam radiation therapy.

The April 3rd, 2012 issue of ZeroHour from the Project to End Prostate Cancer contained two articles of specific interest. One described a study concluding that oxygen levels measured in tumors might be used as a good predictor of prostate cancer recurrence. The other discussed a new zirconium radiotracer (89Zr-5A10)  designed specifically to target free PSA (a better biomarker of prostate cancer) as opposed to serum PSA. This radiotracer can be used in conjuction with positron emission tomography (PET) to identify metastatic bone lesions in a more specific manner than traditional bone scans.

The April 14th, 2012 issue of the Prostate Cancer Research Institute (PCRI) Weekly  contained information about availability and enrollment in Phase III clinical studies of alpharadin (radium-223 chloride) in hormone-refractory patients with symptomatic bone metastases. Alpharadin uses alpha-particle radiation from radium-223 to kill cancer cells by specifically targeting bone metastases by virtue of its property as a calcium mimic. It is being developed by a Norwegian company, Algeta ASA in collaboration with Bayer.

HisProstateCancer.com, a Website for Wives and Family Members of Men With Prostate Cancer.

Recently I was contacted by a woman whose husband had been diagnosed with prostate cancer at the age of 49.  He underwent a radical prostatectomy and subsequent radiation therapy. Their experience led to the generation of the website, HisProstateCancer.com with its specific focus to wives, partners and family members of prostate cancer patients. I recommend this site for your review.

Cardiovascular Issues and Hormonal Therapy.

In November, 2011, I had my six-month appointment with my oncologist at Moffitt Cancer Center, University of South Florida, Tampa.  My prostate cancer is in remission and I  currently receive no hormonal (androgen deprivation, ADT) therapy with Lupron until my PSA begins to rise. When my micro metastases are not under hormonal control, my PSA doubles in three months hence doctors label my cancer as “aggressive”. But for now, my PSA remains ‘undetectable’ for which I am grateful to God and I am on intermittent therapy to minimize the potential side effects of ADT. I expressed to my oncologist that it was my most sincere prayer that I not die of prostate cancer to which he confidently responded that it was much more likely that I would die of cardiovascular causes instead of cancerous ones. He also specified that I was “too good for participation in clinical trials of new therapies”. I do try to maintain good cardiac health with diet, medication and exercise under the care of a cardiologist.

While I was thankful for the opinions expressed by my oncologist, I recently read several on-line articles dealing with potential cardiovascular and metabolic syndrome side effects related with hormonal therapy. The December 20th, 2011 issue of the Prostate Cancer Foundation Newsletter contained an article which stated that “hormone drugs might not raise heart-related deaths in prostate patients” but for those with a history of heart disease, stroke may pose a higher risk. To further substantiate this conclusion, the December 13th, 2011 issue of the National Cancer Institute (NCI) Bulletin  contained an article entitled “Prostate Cancer Trials Show No Link Between Androgen-Deprivation Therapy and Cardiac Deaths.” A new analysis of eight clinical trial results showed no evidence that ADT increased the risk of cardiovascular deaths in the case of patients with non-metastatic, high-risk prostate cancer. The original article had been published in the Journal of the American Medical Association (JAMA) by researchers from the Dana-Farber Cancer Institute who cited an additional benefit that men who had been treated with ADT had a lower risk of dying from prostate cancer and other causes than men who did not. Their conclusions however could not be extrapolated to men with a history of cardiovascular disease who could potentially be harmed by ADT.

Hormonal prostate cancer therapy has recently been associated with blood clots. An article by Amy Norton published December 1, 2011 by Reuters Health, stated that hormonal therapy for  prostate cancer “may raise the risk of potentially-dangerous blood clots” according to a U.S. study led by Dr. Behfar Ehdaie of the Memorial-Sloan Kettering Cancer Center in New York and published in the journal Cancer. Dr. Ehdaie cautions that for men weighing their options for prostate cancer treatment, the risk of blood clots and other side effects needs to be balanced against potential  benefits. It is not proven that hormonal therapy itself is the direct cause of the blood clots but men on ADT had a 56% greater chance of developing a blood clot. The clot risk also increased the longer a man was on the treatment. It is possible that hormone therapy’s negative effects on metabolism might increase a man’s fat mass. Men are urged to discuss the risks and benefits of hormonal therapy and other treatments with their physician.

 

Prostate Cancer Research Institute (PCRI) Insights – must reading.

The Prostate Cancer Research Institute (PCRI) publishes a newsletter called “PCRI Insights” to which I strongly suggest an on-line subscription. The last issue I received was the November issue. The general website for the PCRI is http://prostate-cancer.org/pcricms. It is also listed in the Medical Resources section of this website. The November issue (Vol. 14, No. 4) included a feature article on Provenge (Sipuleucel-T), the immunotherapy from Dendreon approved by the Food and Drug Administration for treatment of metastatic, hormone-refractory, asymptomatic prostate cancer patients. The article described in detail how Provenge works as well as its availability, eligibility and cost.

Also included was an article entitled “What’s Your Shade?” citing a method formulated by Harvard’s Dr. Anthony D’Amico by which the stage of one’s prostate cancer can be described by compiling five factors: PSA, Gleason score, percentage of biopsy cores, and results of rectal and pelvic MRI scans. The goal of identifying one’s “shade” is to ascertain potential risk of relapse (low, intermediate or high) after local therapy and subsequent treatment options if needed.  The Johns Hopkins Prostate Cancer Health Alerts issue of January 12th, 2012 contained a very informative discussion of the TNM (tumor, nodes, metastasis) staging system as used to describe a cancer’s clinical stage or how far it has spread.

The PCRI Insights also contain short highlights and abstracts from recent prostate cancer conferences. The November issue contained updated information on several therapies under development including Ipilimumab (Yervoy), MDV3100, ARN-509 (Prostvac VF) and XL-184 (cabozatinib). In a section on conference summaries, it was noted that C-11 radio-labeled acetate PET scanning was a better method of detecting cancer metastases than the current FDA and Medicare-approved ProstaScint methodology. While information in the PCRI Insights may not be applicable to everyone’s specific medical condition, it provides an excellent overview of the current status of diagnostics and treatments.