Newsletter Features 2004

November 2004

Screening―Biopsy―Treatment
The issue of prostate-cancer screening may cause confusion for men who are concerned about safeguarding their health. To screen or not to screen? That is the question. Then there is a biopsy and perhaps a diagnosis for prostate cancer. When to have a biopsy? To treat or not to treat? What treatment? Those and other questions will be discussed on the following pages.

Screening―Biopsy―Treatment

Screening for any disease or condition is defined as testing for signs of disease in an a-symptomatic population. Part of the controversy regarding prostate cancer screening concerns the reliability of the test in determining which of the men tested have the disease and which do not.

Some men have refused screening on the grounds that the uncertainty of the testing procedure results in unnecessary anxiety; the uncertainty whether more screening results in fewer deaths because of prostate cancer. See the March/2004 PCNG Newsletter, at www.pcngcincinnati.org’s archive, for more information. There is also the uncertainty whether treatment for prostate cancer actually prolongs life (see the Oct/2004 PCNG Newsletter). Prostate cancer patients argue that quality of life is severely diminished after a diagnosis of advanced prostate cancer―screening may result in the detection of prostate cancer before it is advanced. Prostate cancer patients are typically in favor of screening, and so is the PCNG.

Those men who have undergone treatment favor prostate-cancer education and informed consent prior to undergoing prostate-cancer screening, biopsy, or treatment for prostate cancer. We combat fear and ignorance with education. Proper education regarding the issues involved in prostate cancer can dramatically enhance the decision-making process and improve outcomes for the patient and his loved ones.

PCNG Supports Screening

The PCNG (Prostate Cancer Networking Group, Greater Cincinnati) strongly supports testing for the early detection of prostate cancer. Men should begin their testing at the age of 35─for those having a family history of prostate cancer or who are of African American descent─ or at the age of 40 for all other men. Most men will not need annual testing, biannual testing may be good enough.

Effective testing combines both a prostate specific antigen (PSA) blood test and a digital rectal exam (DRE), combined with an explicit statement about the testing and its implications, including biopsy and treatment.

Below is an example of such a statement:
1. Men are strongly encouraged to keep good records of their results, preferably by asking for photocopies of the test results, and keeping those copies in a folder or binder.
2. If the PSA is unexpected high, some action must be taken. Here are examples of annual PSA sequences in which the last PSA value is elevated, and a cause for further action: 0.9, 0.9, 1.1, 1.2, 1.4, 1.3, 1.4, 2.6, or 2.3, 2.7, 2. 9, 3.2, 3.5, 4.5 ng/mL. Notice that in the first example the PSA shows a sudden increase while still below the official 4 ng/mL limit.
3. Elevated PSA levels may indicate the presence of very treatable urinary conditions, such as prostatitis or benign prostatic hyperplasia (BPH), and do not necessarily indicate that cancer is present in the prostate. There are other possible causes such as the digital rectal exam (DRE). Have the DRE after blood is drawn for the PSA test! Also, ejaculation may elevate PSA level for 24 to 48 hours (no sex in the two days before testing); catheterization or acute urinary retention can elevate PSA level for at least two weeks, and prostate biopsy or TURP (transurethral resection of the prostate) for up to six weeks.
What to think if there is a truly elevated PSA?
    • Prostatitis is a possible explanation. Four to six weeks of an antibiotic against prostatitis could be prescribed, and followed by a repeat PSA-test that measures both the total PSA and the ‘free PSA’ percentage. A free PSA percentage of over 25% is associated with a low risk of prostate cancer and a free PSA percentage of under 15% is associated with a higher risk of prostate cancer.
    • BPH can also explain the high PSA. An estimate of prostate gland volume by DRE or via TRUS (transrectal ultrasound of the prostate) may reveal a prostate larger than normal. A general rule of thumb is that an accurate gland volume (best determined by TRUS) x 0.066 will equal the amount of benign-related PSA. For example, a large (60 cubic centimeter) prostate secretes approximately 3.96 ng/mL of PSA into the blood.
4. Blood sampling for PSA determinations, done at least three months apart, and by the same laboratory using the same testing procedure, are necessary to establish PSA ‘velocity’ (PSAV) and PSA ‘doubling time’ (PSADT). The validity of such determinations is increased if such testing involves at least three determinations over a 9-18 month span of time. A progressive and serial increase in PSA values should raise flags of concern that prostate cancer is present and a greater degree of vigilance is mandatory.
    • PSAV is the change of PSA over time. A PSAV that exceeds 0.75 ng/ml/yr is associated with a higher probability of PC.
    • A PSADT is the time in which the PSA doubles. The PSA of a man 40, 48 and 48.5 years old was 0.8, 1.2 and 1.6. The DT between the 0.8 and 1.2 PSAs was about 14 years, but between 1.2 and 1.6 it was 1.2 years! (PSADT=log2xdT/(logB-logA).
A PSADT of less than 12 years is associated with a higher probability of PC.
5. Recently, an additional new screening tool has become available. Bostwick Labs (tel. 800-214-6628) now offers the uPM3 test, the first urine-based genetic test for prostate cancer. uPM3 is based on PCA3, a specific gene that is profusely expressed in prostate cancer tissue. On average, the incidence is 34 times greater in malignant prostate tissue as opposed to benign prostate tissue. No other human tissues have ever been shown to produce PCA3. The uPM3 test predicts cancer as confirmed by prostate biopsy with 81% accuracy, compared to 47% accuracy for the PSA test. Therefore, after an elevated PSA, further investigations such as free PSA and uPM3 testing may enhance the accuracy of diagnosis. The cost of the uPM3 test is $350.

Making the Decision to Biopsy

The standard for an elevated PSA has until recently been a PSA level of 4.0 ng/ml. Lowering the threshold of the PSA level to 2.5 ng/ml will significantly increase prostate cancer detection but it may also increase the proportion of “unnecessary” biopsies.
It has been estimated that only 25-35% of prostate biopsies each year in the U.S.A. find PC. Hence, biopsies should not be performed unless there is a persuasive indication that cancer may be present. One such indication is an abnormal DRE (a nodule, hardness, or other irregularity). This, with or without an elevated PSA level, may warrant the need for a biopsy.

The following should be considered before the decision whether or not to biopsy is made:
• Rule out prostatitis. With the use of a urine culture, antibiotics, and the uPM3 urine test, it may be possible to rule in or rule out prostatitis.
• Rule out BPH. This can be done (1) by calculating prostate size with the ultra-sound measurement of the prostate, (2) by using the uPM3 urine test, and/or (3) with the use of the free PSA percentage.
• Free PSA is a sub-type of PSA; a free PSA percentage of less than 15% should be considered a possible “flag” for PC, and biopsy would be warranted.
• Other flags for PC include a PSAV of 0.75 ng/ml/year or higher, or a PSADT of less than 10 years. Consider the uPM3 test!

Biopsy is the only definitive method we currently have of positively diagnosing prostate cancer. However, a negative biopsy does not guarantee freedom from disease. Biopsy is a sampling of the prostate tissue only, therefore a negative biopsy should always be followed by vigilant monitoring with PSA and DRE to note any progressive increase in PSA levels, and to be certain that any palpable nodes are detected early.

The biopsy is used to determine if a man has PC or a pre-cancerous condition. The biopsied tissue provides valuable information about the grade and aggressiveness of the cancer and is helpful in predicting if the cancer has spread beyond the prostate gland. See the Jan. 2001 issue of PCRI Insights for details, at www.prostate-cancer.org.

However, biopsies should be understood in light of their accuracy. Sextant (6 needle) biopsies with grey-scale ultrasound have been shown to produce a false negative rate of 20% and the use of this method is waning. Currently, 10 or more biopsy cores are obtained and the false negative rate has decreased modestly. Specifically, pathology references to hyperplasia (or hypertrophy) usually indicate BPH (an enlarged or enlarging prostate), and references to inflammation usually indicate prostatitis, both of which are non-cancerous urinary tract conditions and possible causes for elevated PSA levels.

The Diagnosis is Prostate Cancer

The prostate cancer diagnosis is made by a pathologist. Ask for a copy of his report! In it are two very important numbers: Gleason score (or sum), and the percentage of cancer in the biopsy cores (ranging from 5 to 100%). The Gleason grading system consists of primary and secondary grades, each ranked in aggressiveness from 1 to 5. The Gleason score indicates these two grades in the format of primary grade, secondary grade, e.g., 3,4. The patient should insist on a second opinion regarding the measure of the aggressiveness of the cancer, the Gleason score―it should always be verified by an expert in prostate cancer pathology.

A second opinion on the pathology is usually covered by insurance―call your insurance company to understand your insurance! A copy of the original pathology report with the actual biopsy cores are sent to the outside reviewer. Nationally well-known experts specialized in prostate cancer pathology include Drs. David Bostwick (Virginia, 800-214-6628); Jon Epstein (Johns Hopkins U., 410-955-5043), John McNeal (Stanford U., 650-725-5534), and Jon Oppenheimer (Tennessee, 888- 868-7522). Your primary-care doctor or specialist can initiate such a 2nd opinion but you need to request this and ask for a specific physician or lab to be used.

Remember that a diagnosis of prostate cancer is rarely fatal in these times, due to detection at earlier stages of disease. Most prostate cancers won’t kill! Screening is responsible for this shift, from diagnosis of a generally fatal disease 15+ years ago to the diagnosis of a generally controllable disease today. Patients who determine through further testing that their cancer is indolent or insignificant are candidates for a disease management strategy involving vigilant monitoring and lifestyle changes: Active Watchful Waiting (AWW). So the next question after “To screen or not to screen?” should be: “To treat or not to treat?”

This provocative statement is of interest only for those with a Gleason score of 6 (3,3) or 7 (3,4—not 4,3!) and a PSA < 10, especially those who are elderly. Interestingly, there are virtually no data that indicate that RP or radiation for those patients would be better than AWW. The only trial comparing radical prostatectomy with watchful waiting in early prostate cancer concludes that “..radical prostatectomy significantly reduced disease-specific mortality, but there was no significant difference between surgery and watchful waiting in terms of overall survival.” (N Engl J Med. 2002, Sep 12).

There are advantages and disadvantages for both approaches. One advantage of treatment is the feeling that action was taken, the troublesome period of cancer is over! The disadvantages of treatment are the possible side-effects: incontinence and impotence. “At 5 years after treatment, erectile dysfunction [ED] was more prevalent in the radical prostatectomy [RP] group than in the external-beam radiotherapy [EBRT] group (79.3% versus 63.5%;..). Approximately 14%-16% of radical prostatectomy and 4% of external beam radiotherapy patients were incontinent at 5 years ... Bowel urgency and painful hemorrhoids were more common in the external beam radiotherapy group than in the radical prostatectomy group.” (5-year follow-up: J Natl Cancer Inst. 2004, Sep 15). More men appear to suffer more from incontinence than from impotence!

For which men is treatment necessary, and which men can safely forego treatment? Many of us (PSA < 10, GS 6 or lower (2nd opinion), DRE negative) may postpone that decision for months, even years. During that time they will be on AWW. Diet modifications involve 1) eating less, 2) eating less fat, 3) eating more vegetables & more fruit, and 4) eating more fish, and the use of supplements like 5) vitamin E, 6) selenium, and 7) lycopene. Another important aspect of AWW is that the patient has the time to learn what is meant with terms used by the experts, to become more familiar with prostate cancer. How many of newly diagnosed men know how much cancer was found in their biopsy cores? And how many knew that pathologists can make errors and that a second opinion on the pathology report (based on the same biopsy material sent to an eminent pathologist experienced in reading prostate cancer biopsy slides) is an important step in staging and is generally paid for by insurance?

The PSA is monitored regularly during AWW. An important prognosticator, the PSA doubling time (PSADT), can be calculated from successive PSAs. In a series of 231 WW patients the median doubling time was 7 years; those with a PSADT less than 3 years were offered local therapy (Clin. Prostate Cancer 2003, Sept.). One hundred eighty seven patients diagnosed went on WW between 1993 and 2000; thirty eight patients (22%) received delayed treatment: 15 RP, 17 EBRT, and six brachytherapy (BJU Int. 2004, March). Why was delayed treatment chosen by these 38 patients? The choice was based, in order of significance, on their age, PSA doubling time, and the percentage positive cores.

In our opinion the disease-management strategy for many men diagnosed with prostate cancer is on more solid ground if the diagnosis is followed by at least a few months on AWW with regular PSA tests.

When decision is made for local treatment, the first action could be contacting your insurance company, asking about the boundary conditions of the therapy. Can a patient choose any of the doctors practicing in Cincinnati? Is reimbursement given if a patient chooses to go outside Cincinnati? (never for travel and motels). It is now generally recognized that physicians doing RP, EBRT, or brachytherapy frequently, have better results than those doing it less frequently. Ask how many patients have been treated by your doctor!

Systemic treatment for patients recently diagnosed is typically hormonal therapy, also known as ADT, for Androgen Deprivation Therapy. This treatment consists of a LHRH: Lupron or Zoladex, with or without an antiandrogen (AA) such as Casodex, Eulexin, or Nilandron. Orchiectomy is also an ADT, but is now less common than the other methods. ADT can accompany a local therapy (RP, EBRT or brachy) for patients with advanced disease, but without PC tumors in the bone), or is given alone (for patients with tumors in the bone).
ADT is also taken by patients who shy away from local therapy because of the possible side-effects. They take LHRH+AA (or a triple dose of Casodex, without a LHRH) for at least one year, and they stay off therapy (while taking Proscar or Avodart) as long as the PSA remains low (Leibowitz method). ADT “doesn’t actually cure prostate cancer, but merely kills off a majority of the cancer cells. This killing process typically takes 9-12 months to complete... If hormonal therapy continues, there is a strong tendency for hormone-resistant cells to emerge.” (Prostate Forum, v. 8 no. 9, Oct. 2004). Periods without ADT follow thus periods with ADT. This intermittent ADT appears to be successful because androgen deprivation can kill a large number of cancer cells while rendering the surviving cancer cells dormant.

Patients in Cincinnati rarely take the intermittent ADT route. They don’t see specialists other than urologists advising RP or radiation therapists who prefer EBRT or brachytherapy. Oncologists might be more willing to prescribe intermittent ADT—physicians specialized in prostate cancer are typically oncologists. Such specialists can be found at the west or east coast, but not in Cincinnati.

Men diagnosed with late-stage disease have limited choices, generally ADT followed by chemotherapy. So in the end, screening may make it possible to detect prostate cancer before it is in a late stage. Waiting for symptoms of prostate cancer to appear is risky business. Early-stage prostate cancer typically produces no symptoms and by the time a patient presents with symptoms, he is typically beyond the window of opportunity for successful treatment.

We encourage all prostate cancer patients to be knowledgeable about their disease. Learn the basics, ask questions, read the literature, use the Internet, and you will find yourself much more at ease in your communication with physicians. Patient education empowers men to comprehend the pros and cons of their treatment options and to achieve superior outcomes. Stress and depression are, however, common after diagnosis, but self-empowerment of the patient through knowledge can be an excellent remedy.

Patients are not alone─they can discuss their options with their partners and friends, or in support groups such as the PCNG. But most important, they should discuss their options with their physicians.

The PCNG of Greater Cincinnati does not have a help line. If men want to discuss their situation they are encouraged to call the PCRI Helpline (1-800-641-7274). Help can be given to understand PSA testing or DRE results, and help deciding to have a biopsy, or deciding what therapy is best.

This text is partially from PCRI’s website: http://www.prostate-cancer.org and from writings by Donna Pogliano, co-author of "A Primer on Prostate Cancer, The Empowered Patient's Guide"―this text does not constitute medical advice, but is an encouragement for patients to continue their education in all matters regarding prostate cancer.

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October 2004

PubMed

Three physicians have been invited to present talks in the 4th Annual Greater Cincinnati Prostate Cancer Forum. Who are they? This question can be answered, partially of course, by looking in PubMed (ncbi.nlm.nih.gov/entrez). One enters their name and the words ‘prostate cancer’, and citations will be listed, many with abstracts. The number of citations of articles on prostate cancer by Drs. Crook, Dreicer, and Moul is 192. This is an overwhelming number, and reading the titles and abstracts is daunting, though it becomes obvious quickly that all three are experts on the topic they will discuss at the 4th Annual Forum. We strongly encourage you to attend the Forum!

PubMed is a great source of information. The abstracts can be excellent, conveying the gist of an article, or they can be utterly useless, or something in between. But more and more citations have links to the full text of the article and one does not need to have gone to medical school to read such an article. If the full text of an article is not available on-line, nearly all can be found in the UC library. Reading is not necessarily understanding (neither is hearing at the Forum), but much can be understood when reading slowly and using one’s common sense.

We believe that the successful patient is the patient whose education will empower him to choose his own destiny. The patient learns by listening to others: the speakers of the 4th Annual Forum; his physicians, and also his fellow-patients at meetings such as US-TOO (PCNG in Blue Ash) and Man-to-Man (chapter in N Kentucky). We learn by reading books ― in our opinion the best book is still “A Primer on Prostate Cancer, the Empowered Patient’s Guide” by Dr. Stephen Strum and Donna Pogliano. Every patient ought to own this book.

We also learn by reading the abstracts in PubMed and some of the articles, either on-line or in the library. Will we be confused? Of course, we will be. But that is the path to learning and understanding― the path to choosing your own destiny.

Below are two recent abstracts from PubMed about Watchful Waiting and Radical Prostatectomy; the full text of the second abstract can be read after registering at NEJM – this is free.

JAMA. 2004 Jun 9;291(22):2713-9. Natural history of early, localized prostate cancer.
Johansson JE, et al. Department of Urology, Orebro University Hospital, Orebro, Sweden.
CONTEXT: Among men with early prostate cancer, the natural history without initial therapy determines the potential for survival benefit following radical local treatment. However, little is known about disease progression and mortality beyond 10 to 15 years of watchful waiting.
OBJECTIVE: To examine the long-term natural history of untreated, early stage prostatic cancer. DESIGN: Population-based, cohort study with a mean observation period of 21 years.
SETTING: Regionally well-defined catchment area in central Sweden (recruitment March 1977 through February 1984).
PATIENTS: A consecutive sample of 223 patients (98% of all eligible) with early-stage (T0-T2 NX M0 classification), initially untreated prostatic cancer. Patients with tumor progression were hormonally treated (either by orchiectomy or estrogens) if they had symptoms.
MAIN OUTCOME MEASURES: Progression-free, cause-specific, and overall survival.
RESULTS: After complete follow-up, 39 (17%) of all patients experienced generalized disease. Most cancers had an indolent course during the first 10 to 15 years. However, further follow-up from 15 (when 49 patients were still alive) to 20 years revealed a substantial decrease in cumulative progression-free survival (from 45.0% to 36.0%), survival without metastases (from 76.9% to 51.2%), and prostate cancer-specific survival (from 78.7% to 54.4%). The prostate cancer mortality rate increased from 15 per 1000 person-years (95% confidence interval, 10-21) during the first 15 years to 44 per 1000 person-years (95% confidence interval, 22-88) beyond 15 years of follow-up (P =.01).
CONCLUSION: Although most prostate cancers diagnosed at an early stage have an indolent course, local tumor progression and aggressive metastatic disease may develop in the long term. These findings would support early radical treatment, notably among patients with an estimated life expectancy exceeding 15 years.

This article is the first study that follows a group of patients for 20 years after diagnosis; it finds a surprising acceleration in the recurrence and mortality rates of the patients after 15 years, and it recommends radical prostatectomy and not watchful waiting for patients with low-tumor volumes. It is also an article about ‘pre-historic’ patients: no PSA was measured, no PSA doubling times were known. The Gleason score was unknown as was the knowledge that the success of watchful waiting depends on the patient’s Gleason score (GS). Those with a GS of 5 do better than those with a GS of 6, and the 6es better than the 7s. But the Gleason score of a biopsy does not always agree with that from a RP. They were different in 141 (64%) of 222 patients in a study published in J Urol. 2001 Jul;166:104-9. The GS was underestimated in 102 (46%) cases and overestimated in 39 (18%).
Let’s now have a look at radical prostatectomy, the gold standard according to some surgeons. Is it really better than watchful waiting? Fortunately, we have one study comparing the two therapies:
:
N Engl J Med. 2002 Sep 12;347(11):781-9. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. Holmberg L et al. Regional Oncologic Center, University Hospital, Uppsala, Sweden. Click, in www.pcngcincinnati.org, on this link, HTML, for the full-text article. You may have to register―this is free.
BACKGROUND: Radical prostatectomy is widely used in the treatment of early prostate cancer. The possible survival benefit of this treatment, however, is unclear. We conducted a randomized trial to address this question.
METHODS: From October 1989 through February 1999, 695 men with newly diagnosed prostate cancer in International Union against Cancer clinical stage T1b, T1c, or T2 were randomly assigned to watchful waiting or radical prostatectomy. We achieved complete follow-up through the year 2000 with blinded evaluation of causes of death. The primary end point was death due to prostate cancer, and the secondary end points were overall mortality, metastasis-free survival, and local progression.
RESULTS: During a median of 6.2 years of follow-up, 62 men in the watchful-waiting group and 53 in the radical-prostatectomy group died (P=0.31). Death due to prostate cancer occurred in 31 of 348 of those assigned to watchful waiting (8.9 percent) and in 16 of 347 of those assigned to radical prostatectomy (4.6 percent) (relative hazard, 0.50; 95 percent confidence interval, 0.27 to 0.91; P=0.02). Death due to other causes occurred in 31 of 348 men in the watchful-waiting group (8.9 percent) and in 37 of 347 men in the radical-prostatectomy group (10.6 percent). The men assigned to surgery had a lower relative risk of distant metastases than the men assigned to watchful waiting (relative hazard, 0.63; 95 percent confidence interval, 0.41 to 0.96).
CONCLUSIONS: In this randomized trial, radical prostatectomy significantly reduced disease-specific mortality, but there was no significant difference between surgery and watchful waiting in terms of overall survival.

This is the only randomized trial comparing watchful waiting with radical prostatectomy. Unfortunately, it is for men with palpable disease (DRE is +), not the majority of men presently diagnosed. There is a modest decrease in prostate cancer deaths after radical prostatectomy, but there is no improvement in overall survival. Why? Does RP make the cancer worse if it does not cure? (This is the opinion of Dr. Tom Stamey of Stanford University).

How many patients are actually ‘cured’? That depends on how many years one waits. Let’s look at the very best group of patients in the USA, the ones operated on by Dr. Patrick Walsh at Johns Hopkins. In Urology, 2003 Jul;62(1):86-91 (Khan, Han, Partin, Epstein and Walsh) one can find the numbers.
Of 2897 men who underwent RP between April 1982 and September 2001, 88%, 81%, and 69% of the group less than 50 years old had been ‘cured’ at 5, 10, and 15 years, respectively, after their operation. Of those between 50 and 59 years: 87%, 78%, and 71%; of the 60-69 year old men: 84%, 74%, and 67%; and of the men older than 70 years: 72%, 58%, and 58%.

There is very little chance that any group of patients has better statistics than those of Dr. Walsh, and to read that about 30% of his patients have recurrence after 15 years is disturbing indeed. And this percentage will go up after 20 years! So what happens after recurrence? It all depends on the doubling time of the PSA after recurrence. Patients who died of prostate cancer had a median PSA doubling time of 0.8 years. Patients who did not die of prostate cancer within 10 years of diagnosis had a PSA doubling time longer than 1 year (Albertsen PC et al:J Urol. 2004 Jun;171:2221-5). This is rough reading for those of us with PSA doubling times measured much shorter than 0.8 year!
Patients with recurrent disease can be treated with androgen deprivation therapy, but ADT is also sometimes used together with radiation therapy or immediately after RP. At some locations (e.g., California, Germany) ADT is the initial treatment for low-tumor patients, but as such it is rarely seen in the Midwest.

KD and FS

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September 2004

The Alliance Institute for Integrative Medicine
6400 Galbraith Road, Cincinnati, OH 45236
information from http://www.myhealingpartner.com

The Alliance Institute for Integrative Medicine was founded by its Medical Directors, Steve and Sandi Amoils, MD's, and the Health Alliance of Greater Cincinnati. It is, as a part of Alliance Primary Care, a 501(c)3 non-profit organization.
Since its inception, the center has achieved regional and national acclaim for its unique approach to health and wellness. In 1999, the Alliance Institute was named one of the 6 Top Holistic Health Centers in the country, by New Age Magazine.

Steve and Sandi Amoils, physician acupuncturists, trained as physicians in South Africa, London and the United States. While in medical school, they trained in techniques of naturopathy and osteopathy and were involved in research for both the local African healing system and meditation. Following medical school, Drs. Amoils spent two years traveling around the world, intent on seeking out healers in indigenous medical systems who were achieving “miracle cures” (something that Western medicine could not achieve). This included studying acupuncture in Japan and energy healing techniques throughout the world.
        Steve is certified in Pain Management; they are both Board Certified in Family Medicine. Together, they are involved in the continual practice, learning and teaching of alternative therapies.
        Other physician acupuncturists at the Alliance Institute are Drs. Claudia Harsh, John Sacco and Liz Woolford. Dr. Claudia Harsh, after receiving her M.D. from UC in 1985, became a board certified Obstetrician-Gynecologist. Dr. Sacco is a radiation oncologist with Oncology-Hematology Care, Inc. and a physician acupuncturist at the Alliance Institute, and Dr. Woolford worked for nine years as a family physician.
        Science is now validating many therapies that have been used for thousands of years. Medical schools are adding alternative therapies to their curriculum and people are visiting alternative health care providers at an all-time record high. Some of the latest names for alternative therapies are complementary or integrative medicine. The Alliance Institute prefers the term integrative, and does not view alternative or conventional medical treatments as an either/or approach.
        The philosophy of the Alliance Institute is to combine ancient wisdom with modern medicine in order to maximize the body’s innate potential to heal and rejuvenate. People come to the Alliance Institute for a variety of reasons. Some use its therapies for chronic pain and specific medical conditions that conventional medicine has not been able to successfully relieve. Others utilize our healing services to help restore health after surgery or as an adjunct to traditional medical treatments for a specific illness or disease, such as cancer. And some even come for preventive purposes – they’re in good health, and they want to stay that way.
        The Institute views wellness as much more than just a state of physical health. It also encompasses emotional stability, clear thinking, the ability to love, create, embrace change, exercise intuition and experience a continuing sense of spirituality.
        Therapies at the Alliance Institute include: Acupuncture, Chiropractic Care, Energy Healing, Herbal Therapies, Inspiring Classes/Workshops, Pain Management Techniques, Reflexology, Stress Reduction & Personal Growth Counseling, Therapeutic Massage, and Yoga Therapy.
        Acupuncture is a method of encouraging the body to naturally heal itself and improve its functioning. During an acupuncture treatment, very fine single-use, disposable needles are inserted into various points on the body. Sometimes heat or mild electrical stimulation is applied to the site of the needle insertion. The scientific explanation of acupuncture is that needling the acupuncture points stimulates the nervous system to release chemicals in the muscles, spinal cord and brain. These chemicals will either change the experience of pain or trigger the release of other chemicals or hormones which influence the body's own internal regulating system.
        Does acupuncture hurt? Most patients feel only the slightest pinch as needles are inserted. Some feel no pain at all. Once needles are in place, there is no pain.

Which Meeting Subjects Are Of Most Interest To You

We want to invite speakers to talk about subjects that are of the most interest to those of you who attend our monthly meetings. To this end, at the July meeting we passed out a one-page survey to gauge interest in a wide variety of subjects related to prostate cancer. Each of the 23 subjects on the list got at least one vote and there were two write-ins. The top six vote getters were: 1) Nutrition and Prostate Cancer; 2) Significance of Rising PSA After Local Treatment; 3) Alternative Medicine and Prostate Cancer; 4) Current Prostate Cancer Research; 5) Tests Available to Determine the Location of the Cancer; and 6) Impotence and Incontinence. We will be working to find speakers to address these issues in future meetings.
Thanks to all of you who participated in our survey.

PubMed Abstracts on Nutrition and Prostate Cancer

We did, after learning the results of our survey, the obvious thing to do: we entered “Nutrition and Prostate Cancer” as the search words in PubMed (http://www.ncbi.nlm.nih.gov/entrez/), and got 518 results.

We selected a few abstracts of interest, at least to us:

Erectile dysfunction (ED) most often has a physical cause and today, thanks to Viagra, Levitra, Cialis, and other non-oral treatments, the physiological aspects of ED can be treated successfully. However, without also addressing specific issues of intimacy between a couple, a critical component of a man's emotional and sexual life, these treatments will take that man only so far. Sex involves two people whose feelings must also be recognized. Many men often shy away from talking about their sex life in general, and ED in particular, for a variety of reasons, including embarrassment, frustration, even fear. When a sex life has problems, emotional estrangement can quickly occur. Dealing with the problem, in all its complexity, is the only way to assure that the problem is solved to the mutual satisfaction of both partners.

Without an emotional connection to your sexual partner, you won't develop the deep, satisfying awareness that defines great sex. For those of you who took your sex lives for granted prior to your cancer, this is a golden opportunity. Not only do you have available the means to restore your sexual function, but by talking to your partner about your sex life together you can also bring new emotional perspective to your relationship, creating a stronger, more resilient bond that will enhance your sexual experiences as well as those of your partner.

Facing the many psychological reverberations that ED causes in men and their partners after a prostate cancer procedure is a very important part of treating the condition successfully, which is why sexual counseling can play a critical role.

Q. What are the best ways to initiate change in one's sexual relationship?
A. Talking with your partner is the biggest step you can make since it's never easy to admit that your sexual relationship needs help. Modifying it takes work and time, but knowing those areas that are giving you and your partner trouble will make it easier. You always need to keep the lines of communication open. It's paramount that you speak frankly with your partner about your condition. Be honest about your feelings, sexual needs, and desires. If you both come to agree that counseling is the right course, your partner needs to be part of the process.

Q. When does someone need counseling?
A. When it starts to hurt too much emotionally, whether it is the man or his partner. The earlier a couple seeks counseling, and I like to see couples, the better the results will be. Most of the patients I see have had their local treatment 9 to 18 months before. In that period, the first nine months especially, the couple was being patient but then when the erections did not return as before, they began to get worried and wanted answers. If you find that you cannot satisfactorily resolve your problems, I urge you and your partner to seek additional help. Hopefully, you will find that sexual counseling can be an effective way to strengthen and deepen a relationship while regaining lost pleasure.

Q. What type of medical professional should a couple seek?
A. If there is a department of sexual health connected with the psychiatry or urology department at a major teaching hospital, call and ask for a referral. If not, check your county medical society or state psychological association. You want a mental health professional that is experienced in sexual dysfunction and related disorders, and has treated post-surgical and post radiation prostate patients or has had some experience with patients with a chronic illness.

Q. How long do you recommend that a couple stay in counseling?
A. For the uncomplicated post-treatment couple, with the strengths and weaknesses of most couples, I would estimate about two to three months of weekly sessions. I describe the therapy as an ongoing retreat, a period that will allow them to work closely together. It's a privileged time where they can step back, reassess, and see what they can do to make things better.

Q. What is the general emotional state of the male undergoing counseling?
A. The Hopkins prostate cancer patient already understands that the surgeon has three major goals, in the following order: stop the cancer, prevent incontinence, and spare sexual function. Patients are aware of this. The couple that has had minimal sexual activity will not be too traumatized at the loss of erection. However, if sex played a significant part of their relationship, it will be a much greater loss and require more counseling.

Q. What are your goals as a therapist?
A. What I hope will happen is the creation of as much intimacy and sexual expression as possible between the couple. Even if it is not possible to achieve sexual intercourse, it is still possible for sensual pleasuring to take place and I make this clear to the couple. If the man had previously thought that sexual intercourse was the end point in a sexual relationship, I invite him and his partner to now write new sexual scripts for themselves. This works to diminish sexual estrangement between the couple.

Q. What type of medical professional should a couple seek?
A. If there is a department of sexual health connected with the psychiatry or urology department at a major teaching hospital, call and ask for a referral. If not, check your county medical society or state psychological association. You want a mental health professional that is experienced in sexual dysfunction and related disorders, and has treated post-surgical prostate patients or has had some experience with patients with a chronic illness.

Q. Is it difficult for a man to review his sexual history with a therapist?
A. Most couples have difficulty talking to each other about their sexual life. Granted, they can talk about sex in general, for example, sex in the news, but when it comes down to the man and his partner, it's often a challenge to talk about their sexual wishes and concerns. Therefore, it really comes down to the level of comfort that's established by the therapist with the couple. "I'd like to get an understanding of how sex has been for both of you," is a typical non-threatening question asked of the couple in the first session. With each one answering in turn, an easy dialogue is created that should carry over for the rest of the meetings.

One of the things I ask couples soon after we've met for a few sessions is why they have intercourse. "Pretend I'm from Mars," I'll say. "Why do you humans do this sex thing?" Oftentimes, through this ensuing dialogue, the couple comes to realize that it's more than an erection, more than orgasm, that sexually attracts them to each other. I will ask the man and his partner to look inward and bring out into the open issues that may have been waiting beneath the surface. To make their bond stronger, to create a trusting atmosphere that will foster growth, to progress to a mutually-fulfilling relationship, the couple has to find out how each one really feels about sex. This can encompass everything from the meaning of sex in their relationship, and their reactions to utilizing ED therapies, to their degree of personal sexual satisfaction, identifying sexual problems, and anxieties related to intimate matters.

Q. If sex was a big part of a relationship, will the relationship be permanently broken if erections don't return?
A. Sex is frequently made to carry more of an emotional burden than it should. A therapist has to first see how the couple is handling the death threat imposed by the cancer. This means that the couple has to come to terms with what the cancer has done to their lives. Even though the prognosis is often good following a radical prostatectomy or radiation treatment, 99.9 percent of the couples are still jarred by a cancer diagnosis. A woman has been forced to picture herself as a widow, while the man has had to come face to face with his mortality. A couple that comes in for counseling may be totally focused on their sexual life and don't typically say they're suffering from the angst of dealing with mortality. It must be recognized in order for true healing to take place. They then need to be able to find joy in their lives together again. They need to be grateful for the days, for the time that they have together, taking the baseline that is there in terms of intimacy, the emotional as well as sexual, and build on it to make it even better.

Q. How do you counsel the man who is devastated by his inability to get an erection?
A. If the man is really depressed about his inability to achieve an erection, then he will need special care. Treatment for this depression includes medication, counseling, or a combination of both. These treatments not only improve behavior and mood, they also reduce suffering and enhance quality of life. Family and friends are usually the first to notice the changes in behavior and mood, and should encourage the man to seek the evaluation of a doctor or mental health professional when symptoms are severe or last for two weeks or longer. Some symptoms to look for include a persistent sad or 'empty' mood, loss of interest or pleasure in ordinary activities, fatigue or loss of usual energy, sleeping problems, including insomnia, early waking or oversleeping, loss of appetite or overeating, difficulty concentrating, remembering, or making decisions, and feelings of guilt, worthlessness or helplessness.

Q. Does the difficulty or inability in achieving an erection bring about a sexual reawakening in some men?
A. Yes, it does. Some men have been so intercourse-oriented that they never really understood the power of romance and what intimacy really meant for their partner. Without being able to have an erection or to sustain one as before, they soon come to realize that something as simple as a hug or gentle back rub or massage helps firm the intimate bond between the couple.

Q. Is it difficult to convince a resistant man to create new sexual scripts?
A. ED is really a couple's issue. It's a question of the couple being educated about various options and then, being respectful of their esthetics and values, having them understand that they are being given permission to broaden the sexual scripts, to have more variety than there might have been. The couple has to come to realize that it's this sensual pleasuring of each other that can preserve, restore, and enhance the intimacy between them.

Q. What have been the typical responses from patients after completing a full counseling session?
A. Uniformly, they are grateful for having done it because communication and intimacy have improved. How things actually work out sexually, depends on the pre-cancer sex baseline, how often and how satisfying sex used to be, and secondly, the effects of the treatment on their sexual performance. Even if there is not a return to baseline, I think most couples feel the counseling is extremely beneficial because it helps cement their intimacy and lets them come to terms with their new physical reality.

…………when it comes to what it’s going to do to your marriage, you're on your own, and I don't have any doubt that this adds considerably to the level of anxiety on both sides”. This is a citation from Michael Korda’s book “Man to Man, Surviving Prostate Cancer”, one of the other books on prostate cancer.
   We are all familiar— at least we ought to be familiar—with books such as “Dr. Walsh’s Guide to Surviving Prostate Cancer” or “A Primer on Prostate Cancer, An Empowered Patient's Guide” (by Stephen B. Strum, M.D. & Donna Pogliano). Those books give exquisite technical detail but are of limited help in the discussion of impotence, the subject that men find most difficult to talk about.
   Korda writes in his book that prostate cancer will try your soul and the soul of the partner who loves you, but when faced “courageously—and people have more courage, generally speaking, than they give themselves credit for—it can strengthen a marriage and, surprisingly, show you that not only is there life after prostate cancer, but that the best may still be to come.”
   Korda had prostatectomy, but his words are also true for other treatments of prostate cancer. And returning to the nitty-gritty of our disease, it remains a good thing to be well informed about new developments. Therefore, page 3 gives some information about a new application of Viagra, namely restoration of the erectile nerves after treatment for prostate cancer.

“…at the very least, there ought to be some discussion of the issue of impotence…”

    Before and after prostate-cancer surgery, as I would discover, are different worlds, and you cannot imagine the second when you are still in the first.
    Thanksgiving weekend Margaret and I spent together quietly, trying not to think about what lay in store for both of us. I had no doubt that Margaret’s role would be as difficult as mine―perhaps in some ways more difficult, because everyone's attention is naturally focused on the patient's problems, whereas the fears, problems, and feelings of the patients spouse or companion go largely ignored. It's not just that sickness often results in a reversal of roles―the strong person in a relationship may suddenly become the weak one, the caretaker needs caring for, the person who has always looked after things now needs looking after, and so forth―it also creates feelings that can't be acknowledged, that can't, perhaps, even be admitted to oneself.
    It's hard to argue with a man who has cancer, and even harder to be angry with him, and yet women often do feel anger, inevitably―anger that their lives are being upset, anger at being abandoned, however innocently; for serious illness is a kind of abandonment, in which the patient becomes totally immersed in his own case, in his own health, his own needs.
    "How could he do this to me?" is what a lot of women must feel, yet they cannot say it out loud, or even think it, without feeling guilty. Fear—fear of the unknown, fear that he's going to die, fear that even if he doesn't die he will emerge from all this a different person—breeds anger, as fear always does, made stronger in this case by the fact that it can't be expressed.
    It's strange, I think, that nobody has written about this side of prostate cancer. Surgeons—mostly men, since urology remains a largely male specialty—ignore it completely. In their view, the woman's role is to be supportive during the surgery and caring afterward, part cheerleader, part Red Cross nurse. To judge by the books on prostate cancer and the advice to patients handed out prior to surgery, one would suppose that every marriage is a bedrock-solid equal partnership, but in real life this is hardly always the case.
    The truth is that prostate cancer inevitably involves the most difficult and frequently unresolved areas of a relationship. The direct threat to a man's sexual identity and ability to perform can hardly fail to have an effect on the relationship. Women must ask themselves how impotence, if it results, will affect the relationship, how they will feel about it themselves, how it will change things. Questions are likely to include: "What will he be like if he can't have sex?"; "How will I feel about that?"; "How will we handle it?"
    It goes without saying that men who can talk to their wives freely about their innermost feelings and fears, not to mention their sexuality, will do better in facing the problems of prostate cancer than those for whom this is not the case, but, frankly, how many people can say that about their marriage? Mostly, these are exactly the subjects that men find it difficult to talk about and share with their wives. The mere fact of being diagnosed as having prostate cancer is not likely to transform the average husband into a sensitive, articulate man, eager to discuss his darkest fears at length with his wife. ..
    You can get all the information you need—though it takes some doing—about Gleason scores, the different ways of attacking the disease, and so forth, but when it comes to what it’s going to do to your marriage, you're on your own, and I don't have any doubt that this adds considerably to the level of anxiety on both sides. ..
    Such questions as these are normal; prostate cancer by definition touches what is likely to be the most sensitive part of any marriage—the sexual relationship—and in the weeks before the surgery, if you are taking the surgical route, there are going to be a lot of strong emotions going on under the surface. Some men may feel a regret for opportunities they turned down; while both women and men alike may wonder what will become of the marriage if the man loses his potency. Blame, fear, mixed emotions, regrets—it is important to recognize that all these are legitimate feelings in the face of something that is certainly going to change your life, either temporarily or permanently. There is a value to smiling through it bravely—the famous stiff upper lip—but that should not preclude a couple's ability to face all this emotional distress squarely. At the very least, there ought to be some discussion of the issue of impotence, which is the thing that most men are afraid of (death tends to run a close second). Not talking about the possibility is a mistake.
    In my case, I made sure that Margaret read all the material about impotence in the books I had found, however reluctant she was to do so. We naturally hoped this would not be the outcome, but at least we knew and understood what could be done about it if it did happen, as well as what would be acceptable to both of us in the way of sexual aids (about which, more later). Once you've talked about it frankly with your partner, you can put the possibility of impotence in the back of your mind rather than letting it become an obsession.
    You cannot leave this to your doctor, or expect that a busy surgeon is going to have the time to transform himself into a marriage counselor or sex therapist—besides which, the recommendations of a man, in this area, may not make any sense at all to a woman. The mere fact that urologists operate below the belt, in the region of desire, does not necessarily convey any special understanding of sexuality, or sympathy toward women—indeed, some urologists have a tendency to think of the sexual organs in terms of "plumbing," and many of their solutions for sexual difficulties involve more surgery and the implantation of prosthetic devices, ignoring the fact that couples can very often find their own ways of dealing with these problems. In any case, a woman's view of what is desirable in this area may be very different from a man’s, let alone a male surgeon’s.
    The period before surgery will determine more than anything else (except perhaps the surgeon’s skill) the speed with which the patient will recover and how he will feel about it. Expect quarrels and disagreements, by the way—volatile issues are at stake. Ignore the Goody Two-Shoes approach that presumes a little good sex and handholding are all it takes to prepare for what's to come. What's needed is a strong, united front—and a realistic, clear-eyed approach to the problems that may follow surgery.
    Be assured, prostate cancer will try your soul and the soul of the partner who loves you, and subject your marriage to the acid test of facing some of life's more difficult problems. Faced courageously—and people have more courage, generally speaking, than they give themselves credit for—it can strengthen a marriage and, surprisingly, show you that not only is there life after prostate cancer, but that the best may still be to come.

For many men, the biggest fear about prostate cancer treatment is whether it will render them impotent.
    But now researchers are studying several ways to preserve a man’s erectile function after prostate cancer. Treatments ranging from regular Viagra before and after surgery to experimental drugs that protect, regrow and replace delicate nerves all are being studied. ..     Even in highly skilled hands, prostatectomy can leave between 20 and 50% of men with significant and long-term erectile dysfunction, depending on the man’s overall health to begin with. Non-surgical treatments for prostate cancer, like radioactive seeds and hormone therapy, can also take a devastating toll on man’s erectile health. ..
    Some studies are trying to determine whether taking regular doses of Viagra both before and after treatment can lower a man’s risk for impotence. Viagra, which increases blood flow to the penis, already is widely used to treat impotence. The difference here is that the drug is being taken several times a week in hopes of preventing problems or to restore erectile function, rather than to simply help a man achieve a one-time erection.
    In a study presented May 10, 2004, during the American Urological Association annual meeting in San Francisco, researchers followed 54 men who had undergone nerve-sparing prostatectomy.
    The study, which was funded by Viagra-maker Pfizer, showed that 29% of men who used nightly Viagra for nine months showed significant increases in erectile function and nocturnal erections compared with just 5% of patients on placebo. What was surprising, however, is that the men returned to normal sexual function even after stopping the drug. The results indicate Viagra had a rehabilitative effect and may help repair nerve damage, said Harin Padma-Nathan, clinical professor of urology at University of Southern California Keck School of Medicine.
    Researchers at Fox Chase Cancer Center in Philadelphia are studying whether Viagra makes a difference if taken after both radiation and hormone treatments. Another study is looking at whether Viagra given before radiation treatment can prevent problems. The week before treatment the men take the drug at least three times, and continue taking the drug for a month after treatment. In addition to me improved blood flow to the penis,
    Viagra may give men dealing with cancer a needed psychological boost, said Deborah Watkins-Bruner, director of the center's prostate-cancer risk-assessment program. "After treatment men are afraid it's going to hurt, and they're afraid of failure. This can help men overcome any psychological issues."

Significant or Insignificant Cancer
From Johns Hopkins’ Dept. of Urology’s Cancer Update, Winter 2003 (http://urology.jhu.edu/news/6/8.html)

Twenty years ago, most men diagnosed with prostate cancer had advanced disease. Only about 25 percent of men were diagnosed with cancer that appeared to be confined within the prostate—and of those, only about half actually had curable disease. Today, the story is nearly reversed: 75 percent of men diagnosed with prostate cancer have clinically localized disease, and at least 80 percent of them are curable…

Today, some men are found to have minuscule amounts of cancer—smaller than 0.2 cubic centimeters, about the size of a pinpoint, captured by sheer chance during a biopsy. For some men, these are cancers that will never cause harm, and ideally, should never have been diagnosed. Which leads to a treatment dilemma: If this kind of small-volume cancer is diagnosed, what should happen? To treat, or not to treat? What should a man do? For some men, these are cancers that will never cause harm, and ideally, should never have been diagnosed.

This is the kind of problem urologists —who, for so many years, could only diagnose prostate cancer when the chance of cure had become uncertain—have always dreamed of having. It’s also, increasingly, a clinical challenge. Exactly which kind of cancer is it—the “good” kind, that seems content to remain in the prostate and never causes harm, or the kind that will be less indolent over time, and needs to be nipped in the bud?

“To what extent are we diagnosing and treating a disease that would progress very slowly, and never threaten a man’s life?” asks urologist H. Ballentine Carter, M.D., who is also a professor of oncology at the Kimmel Cancer Center. “For which men is surgery necessary, and which men can safely forego treatment?” …

There’s also the matter of a man’s age, Carter notes. “In a very young man (in his thirties, forties or fifties), a very small tumor might be significant. But in an older man, a very small tumor probably isn’t significant, because of the time it takes for that tumor to grow and become dangerous.” Even without treatment, cancer that is fairly well-differentiated (to the pathologist, this kind of cancer cell looks fairly normal, or not terribly abnormal), Gleason 6 or below, and localized to the prostate, takes more than 10 years to spread and cause harm.

Thus, “for men who are in their sixties or older, we feel that if we can identify who has low-volume disease, then expectant management may well be a rational approach.” For the last few years, Carter and Epstein have been studying this strategy in men with stage T1c disease. Their results, published in the Journal of Urology with Patrick C. Walsh, M.D., and Patricia Landis, were so encouraging that a larger trial, involving several institutions, is in the works.
In this study, 81 men who fulfilled the criteria for low-volume disease were followed. At an average of two years’ follow-up, 25 (31 percent) had progression of disease. In 22 of these men, every follow-up biopsy showed cancer. In the men who had progression of cancer, PSA density was significantly higher, and free PSA was lower. Thirteen of these men underwent radical prostatectomy, and 12 (92 percent) had curable disease….. “Because the follow-up is short-term, we can’t say that this is an absolutely safe approach,” says Carter. “We think it is, but we’re still trying to learn. What we do know is that the potential here is very exciting, because we may save a lot of men from surgery that they don’t need.”

Dr. Epstein’s Criteria for Stage T1c Treatment:
Stage T1c cancer is significant if…
- It’s found in three biopsy needle cores, OR
- It’s present in greater than half of any one biopsy needle core, OR
- If the Gleason score is 7 or higher, OR
- If the PSA density is greater than 0.1-0.15, OR
- If the free PSA is less than 15 percent.
Stage T1c cancer is probably NOT significant if…
- It’s found in only 1 or 2 needle cores, AND
- It makes up less than half of each needle core, AND
- The Gleason score is 6 or lower, AND
- The PSA density is less than 0.1-0.15, AND
- The free PSA is greater than 15 percent.

The $60,000 question raised on the previous page is: For which men is treatment necessary, and which men can safely forego treatment? Fortunately, few men diagnosed with prostate cancer have to make a decision on the spot. Most of us can postpone that decision. Robert Young was an exception. With a PSA of over 1,000 and a positive bone scan, hormonal therapy was administered immediately. Most men can postpone a decision for months, even years. During that time they will be on watchful waiting (WW), but we think that they should be on AWW: Agressive WW. Diet modifications involve eating less fat, more vegetables, fruit and fish, and the use of supplements like vitamin E, lycopene, and selenium. The PSA is monitored regularly.

But there is another important aspect of AWW: one has the time to learn what is meant with terms such as those used by Dr. Epstein in the previous article. For example:
-----How many of newly diagnosed men know how much cancer was found in their biopsy cores?
-----How many know that pathologists can make errors and that a second opinion on the pathology report (based on the same biopsy material sent to an eminent pathologist experienced in reading prostate cancer biopsy slides) is an important step in staging and is generally paid for by insurance? This is particularly important for men with Gleason scores 6 & 7.
-----How many men know what is meant with PSA density? PSA density can be compared to the BMI, Body Mass Index. A weight of 200 lbs is different for a 5’ man than for a 6’ man: the former is obese, the latter has a normal weight. PSA density is PSA divided by the prostate volume (in cm3). A PSA of 5 means something different for a man with a large 50 cm3 prostate than for a man with a small 25 cm3 prostate. Each TRUS (transrectal ultrasound) report that accompanies a biopsy should include a statement about the prostate volume.
-----How many men know their % free PSA? This percentage should be determined for any man who may have insignificant cancer. The free PSA may be more or less than 15% (see previous article).

During AWW the PSA must be measured repeatedly. An important prognosticator, the PSA doubling time (PSADT), can be calculated from successive PSAs. In a series of 231 WW patients the median doubling time was 7 years; those with a PSADT less than 3 years were offered local therapy (Klotz, L, Clin. Prostate Cancer, 2003, Sept., p. 106-110, abstract).

In another article, published last month, Dr. El-Geneidy (BJU Int. 2004 March, p. 510-515, abstract) describes 187 patients diagnosed between 1993 and 2000. They all went on WW, and 38 patients (22%) received delayed treatment: 15 RP (radical prostatectomy), 17 EBRT (external beam radiotherapy), and six brachytherapy.

Why was delayed treatment chosen by these 38 patients? The choice was based, in order of significance, on their age (p<0.001), PSA doubling time (p = 0.018), and the percentage positive cores (p = 0.022). Notice that the Gleason score was not a predictor of delayed treatment, and neither were PSA density or percentage of free PSA.

In our opinion the disease management strategy for many men diagnosed with prostate cancer is on more solid ground if the diagnosis is followed by at least a few months on AWW with regular PSA tests.

We encourage all prostate cancer patients to be knowledgeable about their disease. Learn the basics, ask questions, read the literature, use the Internet, and you will find yourself much more at ease in your communication with physicians. Stress and depression are common after diagnosis, but we think that self-empowerment of the patient through knowledge can be an excellent remedy.

Kees DeJong, Jerry Glenn, Stan Moczydlowski, Steven Plymire, Jack Ramsay, Fran Stanton, Steve Steiner, and Tom Young

	November		Screening-Biopsy-Treatment
	October		PubMed
	September		The Alliance Institute for Integrative Medicine; PubMed Abstracts on Nutrition and Prostate Cancer
	*August*		PSA and Biopsy Decision Making
	*July*		Carcinogenic Compounds Induced by Inflammation and Meat Frying
	June		Summary of Impotence Treatments & Restoration of Intimacy
	*May*		Excerpts from Michael Korda's "Man to Man" Viagra May Repair Nerve Damage
	*April*		Significant or Insignificant Cancer - What to do?
	March		Robotic RP; Provenge (vaccin trial), and More intense Screening and Treatment did not Lead to Lower Prostate Cancer Mortality
	February		Nutrition for Men with Prostate Cancer (lycopene in particular)
	*January*		MRSI: New Diagnostic Procedure for Prostate Cancer