Newbyadvice

This is a printable version of the webpage. If you hit
(probably a urologist who is a surgeon) recommended. Print on your Browser, you should be able to get a
Consult with, at minimum, a urologist and a radiation copy.
oncologist so you have the advantage of being able to view the problem from different perspectives. If you’re ADVICE TO THE NEWLY DIAGNOSED
interested in cryosurgery, visit the CryoCarePCA Donna Pogliano
website and find a cryosurgeon to consult with as wel . Donna Pogliano is the co-author of the book “A Primer If you have organ-confined disease, you have the ful on Prostate Cancer, The Empowered Patient’s Guide” array of local treatment options open to you. There are ISBN 0-9658777-6-0 and is also a prostate cancer surgical options including both radical prostatectomy activist. Here is an edited version of the post she put on and laparoscopic surgery. Surgery has some side a Mailing List in December 2004. There have been effects that might not be practical or palatable for you, changes in some treatment options since then – notably and it’s lost it’s lustre as the Gold Standard. No matter. the growth in popularity of RALP (Robotic Assisted There are plenty of alternatives. Some form of radiation Laparoscopic Surgery), but most of what she has to say might appeal to you, including permanent seed implants (SI) or high dose rate brachytherapy (HDR), perhaps even as monotherapy if it turns out that you have a The background to her post was a request for advice smal tumor volume. This may be the least disruptive from a man who said he had a Gleason 6 and a PSA of treatment option you can undertake and stil be treated 5.15. He had been recommended by a friend to with a local therapy. Men with incidental disease who consider having radiation treatment rather than surgery are not emotional y comfortable with Watchful Waiting and he was asking for information or advice on these brachytherapy as monotherapy or for focal cryosurgery. Cryosurgery which might be possible using focal cryosurgery to spare at least one erectile nerve might be a consideration if a man’s cancer is confirmed to be Start educating yourself further. You have time.
confined at least at present to only one side of the You don’t need to rush into a treatment decision
prostate. Usual y there are smal sub clinical foci of you may live to regret. At minimum, you should:
cancer in addition to tumors large enough to be imaged, but cryosurgery can be repeated so it provides its own • Have your Gleason verified by an expert
salvage treatment, as long as the cancer is determined • Answer the question: Do I really need to be
to stil be organ-confined. Are you beginning to see how treated or am I a candidate for giving Active
imaging can help you in your decision-making process? Surveillance a try?
You need to know what you’re dealing with before you • If immediate treatment is indicated based on
can start figuring out what to do about it. thorough staging of the extent and nature of
If you have a low tumor volume, the first option you disease, be sure the procedure is done by an
should consider in my opinion, is the least invasive one (Active Surveil ance/Watchful Waiting), not the most • If you are considering local treatment you need
invasive one (some form of surgery). You have garden- to be fully informed regarding the details of how
variety prostate cancer if you have a non-palpable tumor the procedure is conducted, what the side
with Gleason 6 as verified by an expert pathologist and effects are, what the probability of recurrence is
a PSA under 10. You need to monitor your PSA likely to be, what the financial ramifications of
doubling time and velocity so that you can judge the your treatment are and how they will be
tempo of your disease. You need to figure out what handled, and what salvage options are available
else in your life might need to be fixed that might take to you if primary treatment should be
precedence over leaping into treatment for what might unsuccessful.
be relatively indolent prostate cancer. It would help if • If you are considering a form of local treatment
we knew your clinical stage as determined by DRE you need to know how your present age, other
(Digital Rectal Examination). A palpable tumor might health issues, urinary status and priorities
require a more aggressive course of disease figure into the equation.
management as opposed to one that can’t be felt on DRE. The location of the tumor is important. Transitional zone cancers close to the center of the Here is the ful version of what Donna said to him: gland don’t present the same risk for extracapsular penetration as tumors which arise in the peripheral zone. This could be a factor in deciding what course of I’m sure this is way more than you wanted to know, but disease management is appropriate to your stage and there might be other guys out there that could use some grade of tumor. Are you beginning to see why imaging of this information, so I’l try to touch most of the bases. could be important to establish where your tumor is You should have your Gleason 6 reviewed by an expert pathologist experienced in reading prostate cancer Radiation therapy is a highly volume-dependent slides. I would also encourage you to avail yourself of treatment modality. Sometimes men with large glands imaging techniques such as color-doppler ultrasound or or large tumor volumes can benefit from a course of MRI with spectroscopy to establish your true extent of androgen deprivation therapy prior to radiation treatment. This may improve the outcome for certain You need to educate yourself about al the options once patients. Medical oncologists specialize in the principles you know your true extent of disease, not just the one and practice of androgen deprivation therapy. If you your friend might choose or the one your doctor need to use ADT (Androgen Deprivation Therapy), avail yourself of the services of an expert medical oncologist. the way to go is to hit the cancer hard with a ful arsenal Improperly used, androgen deprivation therapy can of weapons while the cancer is weak and the body is strong. Expert medical oncologist Dr. Mark Scholz in Marina del Rey, California often uses Taxotere You need to know your gland volume as wel as your chemotherapy protocols relatively early in the course of tumor volume. If you know your gland volume, you can disease management of advanced prostate cancer, calculate how much benign PSA would be produced by often with good results. Different and sometimes a gland of your size. The difference between that diametrical y opposing opinions regarding how amount and the total amount of PSA would be indicative aggressively to treat patients with advanced prostate of the amount of PSA that might be attributable to a cancer, but the final arbiter is the wel -informed patient prostate cancer tumor, and that amount of PSA can be himself, since he’s the one that lives with the used to calculate your tumor volume. But tumor volume consequences of his own wel -reasoned decisions and location are best determined by LOOKING at the regarding his own strategy of disease management. tumor. As expert ultrasonographer Dr. Fred Lee quotes, “One look is worth a thousand words.” It is not wise to either over treat or under treat your disease regardless of the stage of disease be it early It doesn’t matter what your friends with prostate cancer stage, local y advanced or metastatic, but to know what decide to do. That doesn’t have any relevance in terms treatment is appropriate, you first need to have an of what YOU should do. You are unique in al the world. accurate profile of the extent and nature of your Your cancer is unique, your goals and dreams and disease. We are making great strides in our effort to priorities are unique, your emotional and coping habits develop better tools to enable us to do that, including are unique and the way your body works is unique to the use of USPIO particle scanning to detect lymph you. One thing you BOTH should do is to know node metastases and other technologies, but we need everything that it is possible to know about your cancer to use them wisely and effectively if they are to benefit the patient. Although this should be the province and But before undertaking any local treatment, including responsibility of the medical community, failure to use some flavor of radiation therapy, you should know the the available tools properly and to the benefit of the probability of systemic disease using other markers in patient is sadly, much too prevalent. In such an addition to PSA. Monitoring blood tests such as CGA, environment, empowered patients who know what state NSE and CEA can help to give indication of sub clinical of the art medicine looks like can do themselves a world micro metastases too smal to detect with currently of good. The environment of ignorance in the world of available technologies. Ploidy analysis on the original prostate cancer is al too pervasive, so let the buyer tumor material found in the biopsy sticks can also help beware. The responsibility to obtain quality medical to predict the success of local treatments. PAP can care in this realm rests largely with the patient since help to predict the success of surgery or radiation. there are so many variables to consider, so many There is a detailed discussion of the implications of an personal consequences to weigh and so many elevated PAP and many other issues in “A Primer on controversies to wade through. This might seem Prostate Cancer, The Empowered Patient’s Guide”, overwhelming at first, but the educated patient, written by renowned medical oncologist Dr. Stephen dedicated to the idea of enjoying the best possible Strum and by me. In our book, we outline a strategy of outcome who rises to the chal enge and then uses his disease management designed to optimize outcomes wisdom in the service of others not only extends his own benefits to others, but benefits himself in every way— You can’t cure systemic disease with local treatments. You can debulk the disease, but you can’t cure it. Are you beginning to grasp how much you have to learn Debulking the disease has advantages sometimes for before you make a disease management decision? some patients, but it shouldn’t be undertaken with Share this with your friend. Share it with your doctor. curative intent in patients who already have systemic Both of you need to enlist the help of expert physicians disease because it is doomed to fail. For systemic and both of you need to be proactive, empowered disease you need systemic treatments, such as patients who take responsibility for the direction of the androgen deprivation therapy in one of its many forms, healthcare you receive under the concept of informed treatment with an estrogenic compound, treatment with high dose ketoconazole and hydrocortisone (HDK +HC) Do you know about the side effects of treatment and or treatment with one of the many chemotherapy how your present urinary status might be a factor in protocols, such as Taxotere-based regimens. Taxotere was approved by the FDA for the treatment of prostate cancer because it was demonstrated that it can prolong Surgery often results in side effects that are often not the life of patients with advanced prostate cancer. disclosed, such as penile shrinkage, the potential for These would be some of the available options urine leakage upon arousal or orgasm, as wel as the depending (again) on the nature of the tumor cel wel -known potential for urinary incontinence in varying population, the aggressiveness of the disease, the degrees and impotence in varying degrees that is assessment of the proportion between androgen- usual y more prevalent that usual y stated, particularly in dependent and androgen-independent tumor based on the hands of a less than expert surgeon. Surgery is a the response to androgen deprivation therapy, other risk highly operator-dependent treatment modality and there is a relatively high recurrence rate probably due to the presence of micrometastatic disease, which was not, or And ALSO depending on the preferences of the patient. could not have been identified prior to the procedure. Some patients and doctors favor minimal intervention The knife can’t reach that. In cases in which a surgical and maximum surveil ance as does renowned medical patient is bothered by high volume urinary incontinence, oncologist Dr. Israel Barken. Some are of the belief that an artificial urinary sphincter can be surgical y implanted, but there are other, less invasive remedies incidence of rectal burning and injury, but bowel that can be tried prior to making the decision to employ problems and urinary problems, as wel as persistent erectile difficulties are commonly seen. Some patients sail through a course of daily IMRT treatments given Surgical patients typical y start the recovery process weekdays over the course of several weeks with nothing impotent and tend to improve over time, while radiation but a little fatigue near the end of the treatment and patients typical y have a decline in erectile ability during others have rectal bleeding and skin damage to delicate the recovery period, then experience a return to rectal tissues the equivalent of a sunburn, requiring baseline with whatever potency they enjoyed prior to treatment and then after a few years, tend to experience a decline in erectile ability from their baseline Should impotence be a problem after treatment, many performance. Advancing age may be a variable in remedies are available including oral medications like degree of potency in the years fol owing treatment in Viagra, Levitra and Cialis, the use of a vacuum erectile addition to the impact of the radiation on nerves and device with a constriction ring, or the use of penile blood vessels. The proactive patient can affect his injections with injectible agents in various combinations, outcomes in regard to potency under the “use it or lose made less threatening by use of auto-injectors with thin it” law of nature. And individual differences confound needles. Penile implants are possible for those who are attempts to predict with any certainty the eventual not successful or are not satisfied with less invasive erectile dysfunction or lack thereof, of any individual. measures. Oral erectile medications are often effective in radiation patients as opposed to surgery patients Younger patients and sexual y active men with good because radiation is inherently nerve-sparing. It is erectile ability prior to treatment fare better than older important to maintain good blood flow to the penile men with pre-existing erectile difficulties, and in case tissues to prevent atrophy regardless of the reason for you were wondering, frequent ejaculation or lack thereof the lack of erectile ability. It is believed that penile probably had no affect on whether or not you were atrophy and shrinkage are related to maintaining the going to get prostate cancer. But every now and then penis in the flaccid state for extended periods during the there's a new study (usual y a rather unscientific recovery period. Exercise with a vacuum erectile device analysis based on the recol ection of the men being several times a week and therapeutic doses of oral studied) to swing the pendulum to one side or the other. erectile agents can be used to maintain proper blood flow and increase the probability of regaining unassisted Surgical patients have a pathology report in hand to immediately verify if their cancer was organ-confined, while radiation patients judge their response to Radiation efficacy depends on dosage, and combination treatment by monitoring their PSA over time, enduring treatments with seeds and external beam are PSA anxiety with every blood draw, wondering if any sometimes used to deliver optimal doses more safely rise in PSA is recurrence or just the PSA bump or PSA and with fewer side effects than can be achieved with bounce phenomenon which has no clinical significance one or the other alone. Expert radition oncologists like whatsoever in terms of long term outcomes. Of course Dr. Dattoli in Sarasota and Dr’s Grimm and Blasko in late recurrence in surgical patients ten or more years Seattle can help you determine what dosage and after treatment can undermine the confidence of method of administration of radiation are tailor-made for surgical patients in regard to the success of their your extent of disease if you decide on radiation. treatment as wel , while radiation patients rarely Radiotherapy Clinics of Georgia is a popular mecca for experience recurrence if it has not occurred within the seed implant treatment. Their protocol includes seed ten years fol owing treatment. So there are pros and implants in combination with external beam radiation for cons to weigh and individual preferences to prioritize. al patients. Monotherapy is not an option at RCOG. Radiation of the seed implant type is a very elegant Definitive cryosurgery designed to destroy the entire treatment with a low incidence of rectal burning, but a gland results in profound impotence. Frozen nerves high incidence of usual y temporary urinary difficulties don't recover. Partial y frozen nerves may stil conduct a such as frequency and urgency, difficulty in starting a nerve impulse but failure to treat the entire gland may urine stream and sometimes a burning sensation upon spare tumor cel s as wel as sparing nerves. (This is urination. Al of these can be handled with medications, sometimes an issue with nerve sparing radical at least to some extent. In cases of severe urinary prostatectomy surgery as wel .) The nerve-sparing blockages in men who were probably not wel selected cryosurgery depends on being certain, usual y via for radiation treatment to begin with, catheterisation is saturation biopsy techniques and imaging, that there is used and if there is persistent difficulty, men are taught no tumor detectable on the side of the prostate where to self-catheterise. A man with pre-existing urinary nerves are to be spared. Dr. Gary Onik in Celebration, difficulties is going to find that the difficulties become Florida and Dr. Duke Bahn can be consulted as experts worse after any form of radiation. The possibility of at in focal cryosurgery if nerve-sparing is a possibility least some degree of impotence after radiation depends under discussion. Expert ultrasonographer and in part on the quality of erections prior to treatment, age cryosurgeon Dr. Fred Lee in Michigan says that if the and how sexual y active the man was prior to treatment. patient is potent when he's done with him, he hasn't An alternative to permanent seed implants or high dose rate brachytherapy is external beam radiation and for That’s my reader’s digest condensed version overview some patients, both forms of radiation administration are of treatment options. Starting with the least invasive, indicated. Some doctors use seed implants fol owed by sometimes cal ed “Active Surveil ance”, “Watchful external beam radiation, some feel that some external Waiting” or “Ongoing Objectified Observation” as we beam radiation prior to seed implant has benefits. discuss it in the Primer, and eliminating alternatives that External beam radiation using state-of-the-art IMRT has don’t work for you for one reason or another is a good advantages over 3D conformal beam in reducing the idea. Active Surveil ance is not popular with doctors So, start educating yourself further. You have time. because it doesn’t result in much revenue. But Johns You don’t need to rush into a treatment decision you Hopkins and other centres are helping patients who are may live to regret, particularly if your staging to candidates for Active Surveil ance to optimize their determine extent of disease is not yet complete. There outcomes by doing everything possible to discourage are other treatment options including other forms of disease progression. Active Surveil ance doesn’t mean radiation, other combination protocols, androgen sitting around doing nothing waiting for the cancer to deprivation therapy as primary treatment and a whole progress to the point where treatment is indicated. It bunch of stuff to know, some of which is essential and means active monitoring with PSA’s, DRE’s and annual some of which is relatively more optional. At minimum, imaging to assess tumor location, volume and progression. It means undertaking a faithful regimen of diet and lifestyle modifications, including a prostate • Have your Gleason verified by an expert cancer friendly diet, supplement use, exercise, • Answer the question: Do I real y need to be treated meditation, prayer, yoga, laughter and continuing or am I a candidate for giving Active Surveil ance a education to know what’s going on in the world of prostate cancer in the event the time comes to go to • If immediate treatment is indicated based on Plan B and be treated. Some men don’t have the thorough staging of the extent and nature of patience, wil -power or persistence for this. It’s much disease, be sure the procedure is done by an more difficult than it appears, done properly. Much more chal enging than going in for an outpatient • If you are considering local treatment you need to procedure to have seeds implanted and going through a be ful y informed regarding the details of how the few months of knowing where every rest room in town procedure is conducted, what the side effects are, is. Men who do watchful waiting aren’t just cowards what the probability of recurrence is likely to be, who won’t be treated because of some wimpy desire to what the financial ramifications of your treatment side-step side effects. Active Surveil ance is not for are and how they wil be handled, and what salvage sissies. These men are aggressively attacking their options are available to you if primary treatment disease with every weapon in the arsenal while watching over their shoulder for an ambush. Some men • If you are considering a form of local treatment you can’t handle this emotional y and are never comfortable need to know how your present age, other health that their disease is sufficiently under control. Living in issues, urinary status and priorities figure into the fear can cause problems in the REST of your body in terms of stress, so this is a decision that affects not only the body, but the mind and spirit. Be honest with Proper selection of the patient for a treatment protocol, yourself. Are you going to be so anxious that you can’t proper preparation of the patient for the treatment enjoy life as you once did if you aren’t treated protocol, and minimizing side effects and maximizing definitively? This is a question that takes time to the potential for successful treatment by enlisting an answer. If you try it for a while and you find yourself expert physician are essential elements in our attempt comfortable with control ing your disease as opposed to eradicating it, you’re a winner as long as there is no Good luck. Get back to us with your questions as you dangerous progression that indicates that treatment is go along. Many of your questions, including some you appropriate. If after a fair trial, you are fraught with fear, haven’t yet thought of, wil be answered if you obtain a dread and anxiety, you’re not doing yourself any good. copy of the Primer and read it cover to cover. Then Al primary treatments designed to destroy the prostate you’l know more about prostate cancer than most result in loss of ejaculate and therefore, even though the doctors, and moreover, you’l know it as it applies to testicles stil produce sperm, there is a very, very low YOU. Your doctor has many cases to monitor. You probability of being able to father children in the usual only have your own. So you need to be the expert. manner. There are a few reported instances of men Keep a prostate cancer digest with the results of al the who have had radiation subsequently fathering children, testing you’ve undergone, al the pathology reports, al but not enough to shake a stick at. So if you are the dates and details of treatment undertaken, al the contemplating completing a family, you might want to medications, supplements and other health data that is undertake watchful waiting at least at the outset after pertinent to you, including your history and the details of diagnosis if you are a suitable candidate for Watchful the other health concerns you may have. Your body is Waiting. If you have bulky or aggressive disease and an integrated system, not an isolated one, so what require relatively immediate intervention (as your affects one part of you has the potential for affecting Gleason 8 friend may), he would want to bank sperm your prostate cancer as wel as other organs and prior to treatment to be used later in an artificial insemination procedure if he wishes to father children in I wish you and your friend low PSA’s and may your days the future. We don’t know for sure what effect radiation may have on genetic material so even though the testicles may stil produce sperm which might be aspirated after treatment and used in artificial insemination, we might be more uncertain of the quality of the sperm and the genetic material therein. There isn’t much of a track record to go on here, I don’t think. But in any case, a prudent couple wouldn’t want to have to deal with an uncertain degree risk of birth defects if that possibility could be avoided by means of banking

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