Posts Tagged ‘surveillance’

losers quit when they are tired...winners quit when they win.

Common searches about sex that end up on my site and some other various tidbits for you…

  • Having sex the night before having a PSA drawn can elevate the value.
  • Having sex before the Prostatic Acid Phosphatase will probably elevate the value.
  • A rectal exam before having the PSA drawn will not elevate the value.
  • A rectal exam before a PAP will elevate the value.
  • You don’t get cancer if you have sex with a man with prostate cancer. (Good try ladies.)
  • Your libido doesn’t change (physiologically wise) after the prostate is removed.
  • Climax after radiation or radical prostatectomy still occurs but the character of which may change…for the better or worse.
  • In both radiation or prostatectomy the male’s climax… will be dry or no fluid.
  • You can have sex before a prostate biopsy.
  • You can have sex after a prostate biopsy…expect blood in the semen. It looks dramatic but is harmless. It will stop … in time.
  • If you have chosen radiation because you expect to “spare” your sexual function…think again and research again.
  • There is a bit of luck in being potent after “any” treatment of the prostate. Sorry proton guys…sorry robotic guys whose doctor said he “spared” the nerves.
  • You are infertile after treatment, not impotent.
  • You are less likely to preserve sexual function if your function is waning before treatment. i.e. the guy with a 10 function will do better than the one with a 6.

So…Pick your poison.

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live like you are going to die tomorrow, learn as if you will live forever....

Read the following report see what you think about the quotes and conclusions of Mr. Montgomery’s surgery.

I read for my wife the article and she asked, ” So, he will never need another PSA will he? The doctor said he was cured right?”

Report of Eddie Montgomery’s Surgery and Prognosis

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If you have spent anytime on my little ole site here, you might think that I am obsessed with Frank Zappa. Well, I am not. The deal is that we have very little real life stuff to watch that makes you feel, I mean really and gutturally feel, the tragedy that is a man being diagnosed with prostate cancer when it is too late to cure? I venture to say that this type of scenario should not be happening and is preventable with early awareness, and judicial screening and PSA evaluation.

Something struck me while watching this clip. It reminded me of sitting with my brother Rushton in Pensacola, Florida in a Chemotherapy clinic while he was being treated. We talked about a lot. He mentioned his legacy. I remember he was proud of what he had accomplished with his music. It gave him peace. His feeling that way gave me peace.

I asked Rushton, who was a beautiful person and a good person to everyone, if he had changed his view of God. I asked if he had changed anything about his thoughts or if he had contemplated religion in preparation for dying. Rushton was not a religious person per se but I have no doubt he is in heaven. He doesn’t fit the mold and did not cross all the t’s and dot all the i’s, but he’d have to be in heaven. So I ask, ” Have you prayed for forgiveness and made amends to be right with God when you die?”

“John, I think God is smarter than that. He knows who I have been, what I’ve done and not done. It would be silly to try to fix things now.” He gave me a resignation type of smile like, ” what the hell, what will be will be.” Rushton is heaven, trust me, some type of loophole exists for people like him.

Anyway, back to Zappa, in the interview he remains recalcitrant to the end. When asked what he’d like to remembered for he says, “I don’t care if I am remembered. Leave that to people like Reagan.” He then says that he was angry that he had had trouble peeing for years and nobody did anything. ” To be told you have cancer and there is nothing that can be done made me angry.”

It was a sad interview to watch. Can you imagine how you would feel it it were you or your father? He was 50, the height of his career and had several children. It was evident in the clip that he was a beaten man. If you have bad health it is not like you can buy your way out of it. The video is poignant.

The Otis Brawley’s of the world need to temper their views and statements to consider the “Zappa” kind of patient. It is the “Zappa patient” that awareness and screenings are trying to find. Yea, I see over and over again that only 4% men die of prostate cancer. Tell that to the 25,000 families of the men that die each year.

Listen carefully to the part about prostate cancer. This was 1993. He said he had voiding problems but his cancer was not detected.  Would a PSA have made a difference?

Updated: 11:33 PM Aug 28, 2010

Doctor outlines treatment for prostate cancer
Prostate cancer is known to have a higher incidence rate in the African-American population.

Posted: 12:00 AM Aug 29, 2010
Reporter: Jennifer Maddox Parks
Email Address: jennifer.parks@albanyherald.com

width:290 and height: 219 and picwidth: 211 and pciheight: 159
Dr. Charles Mendenhall, radiation oncologist with Phoebe Putney Memorial Hospital, updated the Dougherty Rotary Club on possible treatment options for prostate cancer.

ALBANY — Not getting regular blood screenings can turn a treatable condition into a silent killer.

Dr. Charles Mendenhall, a radiation oncologist with Phoebe Putney Memorial Hospital, made an address to the Dougherty Rotary Club Tuesday for the purpose of educating the public on prostate cancer — specifically how the disease is detected in its earlier stages and the treatment options that are available.

The best way of detecting the condition early is through the prostate-specific antigen (PSA) blood test. High levels of the antigen, or a level that rises over time, can be an indication of cancer.

“The PSA is the best measurement on how the cancer is behaving,” Mendenhall said.

A PSA level is typically considered high when it gets above four nanograms per milliliter.

After the PSA test, the next thing to consider is the Gleason score, or grade — which measures the aggressiveness of the cancer on a scale of two to 10.

“Eighty percent of the patients I see have a grade-6 cancer,” Mendenhall said.

Before treatment begins, a physician also has to take into account the ethical implications of putting a patient through a procedure from which he or she may not benefit much, Mendenhall said.

“If I have an 80-year-old who has had two strokes, from an ethical standpoint, I may decide I’m not going to treat him,” he said.

The best hope of curing prostate cancer is either through surgery to remove the prostate or radiation therapy.

On radiation therapy, Mendenhall discussed TomoTherapy. Phoebe’s TomoTherapy unit, installed about 18 months ago, allows physicians to use an image-guided approach to map out a specific area of the body in order to administer a more targeted dose of radiation.

“We can map the radiation dose in a 3- to 5-millimeter margin,” Mendenhall explained. “It’s all about treating what you have to treat (and avoiding what you don’t need to treat).”

For prostate cancer treatment, such an approach can allow doctors to better protect other organs in the pelvic region.

“We want to avoid the bladder and the rectum as much as possible,” Mendenhall said.

Brachytherapy, a procedure in which radioactive seeds are implanted through needles using ultrasound for guidance into the prostate where they can irradiate the cancer from within, is also a common method of treating the condition, Mendenhall said.

The survival rate for prostate cancer over a five-year period is 100 percent for localized disease, 100 percent for regional disease and 31 percent for distant (or advanced) disease — numbers that experts say can be misleading.

“Those that are (treated) for prostate cancer and get a recurrence aren’t going to die in five years,” Mendenhall said. “Plus, some of these guys are going to drop dead of a heart attack.”

Incidence rates tend to be higher in the African-American population, which may be an indicator of how common the condition is in Southwest Georgia compared to other regions.

“The incidence rate may be higher here than, say, Leesburg, Pa.,” Mendenhall said.


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a good doctor prescribes the bark of the quinquina when the patient would be obliged to eat the whole tree

He adds that, in general, 15 to 25 percent of men whose initial biopsy shows a low-risk prostate tumor will actually have a high-grade cancer upon further review of the entire prostate once it is removed.

So…how big a boy are you?  It seems to me that some patients wear the decision to pursue active surveillance on their sleeve, as if by doing nothing places them on the cutting edge of prostate cancer treatment. (See Clark Howard post) Here’s a question for you….what is wrong with the philosophy that one will do something when things get really bad? I think you know.

Now back to surveillance. If you know from the get go that you have about a 20% chance that your prostate cancer is actually more aggressive than your biopsy reports suggests, then how does that flavor your confidence to pursue surveillance. I am not saying it is wrong to make that choice, but see it for what it is: possibly making a decision on a flawed premise. Read the report below for yourself. By the way I have a patient that included in this study…he is 80 and enrolled in the program about 3 years ago. ( That’s another thing…if you making decisions on patients that are in their late 70’s and your are mid 50’s, then you are not comparing apples to apples or prostates to prostates.

So, surveillance…are you Okay with risk that while you are waiting for proof that your disease is more aggressive than you thought and that by the time you act….it may not be as favorable  as it would have been if you had acted from the start.

How big a boy are ya?

Johns Hopkins experts have found that men enrolled in an active surveillance program for prostate cancer that eventually needed surgery to remove their prostates fared just as well as men who opted to remove the gland immediately, except if a follow-up biopsy during surveillance showed high-grade cancer.

Active surveillance, or “watchful waiting,” is an option open to men whose tumors are considered small, low-grade and at low risk of being lethal. Given the potential complications of prostate surgery and likelihood that certain low-risk tumors do not require treatment, some men opt to enroll in active surveillance programs to monitor PSA levels and receive annual biopsies to detect cellular changes that signal a higher grade, more aggressive cancer for which treatment is recommended. Yet, according to the Johns Hopkins experts, there is concern that delaying surgery in this group until biopsy results worsen may result in cancers that are more lethal and difficult to cure.

Bruce Trock, Ph.D., associate professor at the Johns Hopkins Brady Urological Institute, and his colleagues compared the pathology results of men in an active surveillance group at Johns Hopkins who later had surgery with those who also had low-risk tumors and opted for immediate surgery.

Results initially showed that 116 active surveillance participants who had surgery were more likely to have high-grade, larger tumors than 348 men who had immediate surgery. But Trock says that these results were found only in 43 (37 percent) men in the surveillance group who were recommended for surgery because a follow-up biopsy during surveillance worsened to indicate a high-grade tumor.

Gee whiz….ONLY 37% of follow-up biopsies during surveillance worsened….That’s good isn’t it….or is that bad?

“We think that these men had high-grade tumors to begin with that their initial biopsy missed, and this group may be over-represented in men who are recommended for treatment after an initial period of active surveillance,” says Trock. He adds that, in general, 15 to 25 percent of men whose initial biopsy shows a low-risk prostate tumor will actually have a high-grade cancer upon further review of the entire prostate once it is removed.

Apart from the 43 men whose pathology results worsened during surveillance, the remaining men in the surveillance group had similar pathology results at surgery to those in the immediate surgery group. “This means that most tumors are not likely to worsen during the period of active surveillance,” says Trock.

The researchers calculate that the risk of finding high-grade tumors in the entire group of 801 active surveillance patients is low — about 4.5 percent per year.

Trock is leading a National Cancer Institute-funded study with four other cancer centers to identify biomarkers that may identify men who have worse tumors than their initial biopsy indicates.

The Johns Hopkins Active Surveillance program, led by H. Ballentine Carter, M.D., of Johns Hopkins, has enrolled 801 men since 1995 and is believed to be the largest such program in the U.S. Fourteen men in the program who later had radiation and four who had radical prostatectomy developed recurrences, but no participants have developed distant metastases and none have died from prostate cancer. Fourteen men in the program died from other causes unrelated to prostate cancer.

The current study was funded by the Johns Hopkins Prostate Cancer Specialized Program of Research Excellence (SPORE) grant awarded by the National Cancer Institute and by Dr. and Mrs. Peter S. Bing. The research also was presented at the American Urological Association Annual Meeting (Abstract #1062).

Based on abstracts and presentations by Johns Hopkins Kimmel Cancer Center scientists at the annual meeting of the American Society of Clinical Oncology (ASCO), June 4-8, in Chicago.


Vanessa Wasta

Johns Hopkins Medical Institutions

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From the “Decision”-  The perfect storm.

So the perfect storm: common misconceptions that give men a false sense of security, an exam they do not want to have done, and the resultant flawed rationalization to skip a prostate evaluation. All of these factors contribute to missed opportunities for early detection.”

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‘Prostatic Evasive Anterior Tumours’: The Role Of Magnetic Resonance Imaging

31 Jan 2010   

UroToday.com – In this recent article, we review our experience and delineate the role of magnetic resonance imaging (MRI) in identifying patients presenting with a raised prostate-specific antigen (PSA) level and clinical findings suggestive of anterior predominant tumors, which appear to be significant, particularly in those with a previous negative biopsy or low-volume disease undergoing active surveillance (AS). [1]

We previously highlighted the important role of MRI in assisting in the detection of prostate cancer (CaP) in men with previous negative biopsies and elevated prostate-specific antigen levels. [2] (also this article appears in Urotoday please insert reference) Furthermore, anterior tumors have been identified and concerns raised regarding the ability to adequately biopsy such lesions as they are not identifiable on digital rectal exam or with most biopsy schemes with invasive methods often utilized to confirm their existence. [3-5] In marrying these two concepts, It was first suggested in Europe by Zerbib and colleagues [6] that MRI may be helpful in identifying anterior tumors in men with CaP.

Although a retrospective study, our database is comprehensive and was able to identify patients with anteriorly predominant tumors on MRI whom had undergone prostate biopsy. MRI had a positive predictive value for anterior tumors of 87% (27/31). In many of the cases, serious adverse pathological features were noted, particularly in those proceeding to radical prostatectomy.

Furthermore, highlighting the importance of anterior prostate tumors, was the recent article by Duffield et al. [7] regarding AS for CaP, which appeared in the Journal of Urology. In this article, for men on AS, the difficulty in recognizing and biopsying anterior tumors was stressed. However, the role of imaging was not discussed and our results confirm that imaging is extremely important in selected men. [8] Although not advocating MRI in all patients on AS, we believe there is a subset of patients either having negative TRUS biopsy or low volume disease undergoing AS who should be considered for MRI and further biopsy as their pathology may be aggressive.

PEATS, standing for “prostate evasive anterior tumor syndrome,” appears to be appropriate in describing men with anterior tumors not palpable at DRE nor accessible by standard biopsy schemes. So our summary is that where discrepancy between PSA, PSA dynamics and either a negative biopsy or low volume prostate cancer managed by AS, think of anterior tumors and think of MRI. Our perspective is that these tumors are actually fairly aggressive and urologists and all physicians should be aware of their potential behaviour. Certainly, this requires further analysis in a large prospective study with particular investigation of the specific triggers for MRI and targeted biopsies which we are now undertaking at our institution.

My thoughts-

I stated in my book that a negative biopsy was a good thing on two fronts. One, the biopsy did not show cancer, and two, it means most probably that you won’t get the bad kind. Bad kind meaning, high volume and high Gleason’s score path report. In my twenty-four year career, I have seen only one time a Gleason’s eight on a repeat biopsy of a gland with a previously negative biospy. I believe this case of mine represts a case similiar to what is decsribed above. In the second biopsy, which was about three years afer the first, there was one small focus of the Gleason’s eight. The patient is in his mid seventies and after evaluation by the radiation therapist , has elected to pursue radiation. I don’t think this situation occurs often, but I like the idea of considering it if there is a negative biopsy, a rising PSA, and concern that something is going but you are unable to confirm it.

This patient, Mr. Gaines, is a friend of mine and I have several of his friends as patients as well. Before Mr. Gaines  first biopsy a friend of his had told him that I had done a biopsy on him and it was essentially painless. Unfortunately the I.V. meds we gave Mr. Gaines did not do much for him and he had much more pain with the biopsy than was intimated by his friend. When I asked how the biopsy went, he said, ” I’m gonna find my friend who said this would not hurt and whip his a..” About a year later the friend that had told  Mr. Gaines that the biopsy would be painless, needed to have cystoscopy, another potentially painful thing I do to people. We gave this patient I.V. versed and proceeded with the procedure and he too unfortunately experienced more pain that I or he would have preferred.  He also commented that the shot had done nothing to him and wondered if my nurse had hit the vien at all. A month later, he developed an issue that required another cystoscopy and when I recommended it he rightfully questioned the aneshesia that he would be getting. “I ain’t gonna do it if all I get is a “Gaines” shot. Now all of Mr. Gaines friends, and I see alot of them, begin any discussion of a procedure with the admonition,”You aren’t  going be giving me a “Gaines” shot are you?”

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NCCN Guidelines For Prostate Cancer Updated To Stress Careful Consideration Of Active Surveillance- Medical News Today

11 Jan 2010   

The National Comprehensive Cancer Network (NCCN) recently updated the NCCN Clinical Practice Guidelines for Oncology™ for Prostate Cancer to reflect new recommendations regarding active surveillance, also referred to as watchful waiting, for men with low risk prostate cancer.

A significant change incorporated into the updated NCCN Guidelines for Prostate Cancer is the recommendation for active surveillance and only active surveillance for many men diagnosed with prostate cancer. Men with low risk prostate cancer who have a life expectancy of less than 10 years should be offered and recommended active surveillance.

In addition, a new “very low risk” category has been added to the updated NCCN Guidelines using a modification of the Epstein criteria for clinically insignificant prostate cancer. Only active surveillance is offered and recommended for men in this category when life expectancy is less than 20 years.

“The NCCN Prostate Cancer Guideline Panel and the NCCN Prostate Cancer Early Detection Panel remain concerned about over-diagnosis and over-treatment of prostate cancer,” says James L. Mohler, MD, of Roswell Park Cancer Institute and chair of the NCCN Guidelines Panel for Prostate Cancer. “Growing evidence suggests that over-treatment of prostate cancer commits too many men to side effects that outweigh a very small risk of prostate cancer death.”

The NCCN Guidelines Panel took careful consideration, including a thorough review of evolving data, of which men should be recommended for active surveillance. The updated NCCN Guidelines now recommend active surveillance for men with very low risk prostate cancer and life expectancy estimated at less than 20 years or men with low risk prostate cancer and life expectancy estimated at less than 10 years.

“Although the NCCN Guidelines Panel stresses the importance of considering active surveillance, ultimately this decision must be based on careful individualized weighting of a number of factors including life expectancy, disease characteristics, general health condition, potential side effects of treatment, and patient preference,” notes Dr. Mohler. “It is an option that needs to be thoroughly discussed with the patient and all of his physicians which may include his urologist, radiation oncologist, medical oncologist, and primary care physician.”

The updated NCCN Guidelines stress that active surveillance involves actively monitoring the course of the disease with the expectation to intervene if the cancer progresses. Patients under active surveillance must commit to a regular schedule of follow-up, which includes a prostate exam and PSA, and which may include repeat prostate needle biopsies.

The NCCN Clinical Practice Guidelines in Oncology™ are developed and updated through an evidence-based process with explicit review of the scientific evidence integrated with expert judgment by multidisciplinary panels of physicians from NCCN Member Institutions. The most recent version of this and all the NCCN Guidelines are available free of charge at NCCN.org.

National Comprehensive Cancer Network

My thoughts-

I have patients tell me all the time they want to “do nothing.” The problem with most who say this is that they are thinking this before the biopsy or the knowledge of prostate cancer exists. In other words, they have heard of active surveillance and the slow-growing nature of prostate cancer and are using this as an argument not to have the biopsy in the first place. You have to know the specifics of the cancer in addition to your overall medical condition and life expectancy to adequately determine if you are a candidate. In general as stated in the article above, favorable parameters of the biopsy and life expectancy of less than ten years make for a good candidate for surveillance. I might add, that for me it was not an option as I was relatively young with a long life expectancy but my mentality was not suitable in this case for doing nothing. I couldn’t just do nothing knowing that there was “something in me.”

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