As all informed readers know, Florida experienced a record number of hurricanes during 2005, not the least of which was Hurricane Wilma.  This late October storm caused, for the second time in Man To Man - Sarasota's history, the cancellation of that month’s meeting.  

                Thus, this issue will report only on the November meeting with additional material from outside media sources.

                The November speaker was Alan H. Porter, M.D., Radiation Oncologist.  He is the Founder and Director, since 1975, of the Sarasota Oncology Center.  A graduate of the University of Florida, he trained extensively at M. D. Anderson Hospital in Houston.  He is a founding trustee of Hospice Foundation of Sarasota, Manatee and Charlotte Counties, and currently is a member of the Physicians Advisory Council and consultant to Medicare-Blue Cross / Blue Shield of Florida.  Here’s Dr. Porter:

                Good afternoon and thanks for asking me to come and talk with you all.  I have done it over the years from time to time and always look forward to it.  My subject today is a talk about treating surgical failure of prostate cancer with radiation therapy.  

The ABCs of Prostate Cancer

                I know many of you are very, very accomplished and conversant with radiation therapy, but I’m going to digress for a moment and cover some basics.  This is just to be sure we’re all on the same page and understand the system and procedure. We’re going on a quick tour of the radio therapeutic approaches to prostate cancer.  I will do my best to be appropriate and precise.

                There are two kinds of delivery systems for radiation therapy;  that is ionizing radiation.  One is external beam and the other is seed implantation.  They both deliver radiation therapy, only the method differs.  

How External Beam Works

                When we plan radiation therapy, external beam or with seed implants, we are using very sophisticated computers.  In the diagram of a man’s anatomy that I just showed you, right at the level of the heads of the hip joints, these are beam angles that come in from linear accelerators.  This is beam number one, although we actually have a choice of four or five entry points for this beam.  Sometimes we get up to nine beams, particularly with IMRT (Intensity Modulated Radiation Therapy).  This is the latest and newest technology that we have available in our practice and it is changing the face of prostate cancer treatment.  

                Now, here is a typical computer printout.  What it does is tell this monster machine, the linear accelerator,  what to do.  The machine weighs around 22 tons, has a head that rotates and will fire a beam, then go to another position and fire another beam, etc., and all at the same target, which we call the isocenter, in the prostate.  That is external beam; external meaning the beam is given from outside the body.  There is no invasive procedure, no surgery;  similar to a chest x-ray, a very fancy x-ray indeed.  IMRT is a very technologically intense treatment giving very accurate and precise delivery of radiation.  The results over the past five years have been outstanding.

Let’s Look At Seed Implantation

                I’ll be using this slide to describe this portion of the talk.  Basically, in the seed implant, we have this patient in what we call lithotomy position, lying on his back, with his legs up in stirrups.  His prostate gland is here and we put an ultrasound probe in his rectum.  At this point, we localize the prostate gland.  Here is the probe itself going into the rectum.  The seeds will go in through needles put directly through the base of the perineum.  In this case, we have one, two, three needles in the prostate and what we will do is put radioactive seeds through those needles in a prescribed fashion and then retract the needles.  The seeds remain and they begin their radiation.

                Here is  a picture, a CT scan, after the implant described above.  Here is the prostate gland, but there is something obviously new here; see those white metallic objects?  They are the seeds; either radioactive Iodine 131 or Palladium 109.  What they do is decay, giving off radiation over a period of several weeks to several months.  Palladium gives up all of its radiation in roughly 17 days; Iodine is a little weaker and all the while it kills the malignant cancer cells.

                 Before hand, we calculated what the proper dose should be for this patient, and the computer instructed the linear accelerator to deliver 16,000 rads.  Remember when you were in high school you learned about the Ranking and the measure of radiation?  Well, the conversion of Ranking to rads in this case is just about one-to-one -- the patient actually received 16,500 rads delivered to center of the target, and lesser amounts away from the center of prostate gland.  Any questions on that?

Would this patient’s condition have permitted a surgical removal of the prostate gland?  If so, why did he choose radiation?

                Yes, he was a candidate for a radical prostatectomy, but why he chose seeds, I don’t know.  There is no reason why you can’t treat primary prostate cancer with radiation now.  With external beam, the physician is really unlimited as to what he can treat.  But, you do get into problems with seed implantation.  There are some patients who are simply not seed implant candidates.  

                One reason is because of the size of the gland -- a large gland, 60 cubic centimeters or larger.  What happens is you put enough seeds in there to do the killing job, and the prostate gets too hot in the center, and you under-treat the outside.  You have to select your seed implant patients very carefully -- I can’t emphasize that enough.  Let’s go back to our anatomy lesson a minute.  What goes right through the center of the prostate?  Right, the urethra bringing urine down from the bladder.  If you over-treat that urethra with radiation, you have a miserable patient suffering from chronic urethritis for a long time.  You never want to do that.

                There are some anatomic variations in addition to size that prohibit seed implantation.  For example, if you have a patient that has had a TURP (roto-rooter) for obstruction, which is very common, most of the time you can’t do a seed implant.  The reason this is not wise is because there was an apple core of tissue taken out of that gland so there is nowhere in that area to put seeds.  There are other contraindications for seed implantation that we’ll have to go into another time.

Back To The Main Subject

                Now that the anatomy and radio biology lessons are over, let us turn our attention to the subject at hand, salvage radiotherapy for recurrent prostate cancer after radical prostatectomy.  Just to give you a little background, there are about 60,000 radical prostatectomy procedures done in the United States per year.  About, and this is an important number, 25% of that 60,000 will have cancer extending beyond the gland. What that means and translates to is, those patients are at high risk for what we call local recurrence.  Local recurrence is the cancer returning to the prostatic bed, the cavity that is left after the surgeon removes the prostate gland.  That is the high risk group we are going to talk about today.

                What we have come to learn over the past several years is that group of patients, even though they have a persistent tumor or a recurrent tumor in the prostatic fossa (bed), are still very curable with salvage radiation therapy.  In other words, we treat that area, not with additional surgery, but with radiation therapy.  I don’t know why we call it salvage therapy -- it’s a terrible word, but it has crept into the literature and it is present.

                The problem is the recognizing and finding of a local recurrence as opposed to a metastasized recurrence.  What is a local recurrence and can we absolutely convince ourselves that there is a local recurrence present, and only present there?  If it is so, then that patient becomes potentially curable with appropriate external beam radiation therapy.

Looking For The Local Recurrence

                This is a changing paradigm in the way we surgeons/radiation oncologists have been thinking over the past seven to ten years.  The first thing we address is the problem of establishing a recurrence.  How do you know, after you’ve had a radical prostatectomy, that you have a recurrence?  The answer is you probably don’t have any symptoms at all so what do you then rely on?  Well, you rely on the only tumor marker there, and the best rumor marker there is, prostate specific antigen (PSA).  Remember, when you have a radical prostatectomy, your PSA is going to go to zero and it’s going to stay zero for the rest of your life.

                If it does not stay at zero, then you have either recurrent disease or persistent disease.  The first PSA test will come into play shortly after a radical prostatectomy and at regular intervals thereafter.  Most of you in this room know more about PSA than the whole group of primary care internists in this community, and we have the best, so that’s a big compliment to you.

So, Where Do We Go Now?

                What is the next step?  The next step is to see if you have a progressively elevating PSA enzyme level; if so, we’re looking for the doubling time.  If, for instance, you have a PSA that comes back at 1.0 and three months later you have another PSA test that comes back 1.5, you have a positive slope from which your doubling time can be projected.  This is your first indication to go further to try to establish that you have persistent disease and then you have to figure out how to deal with it.  

                To do that, we go  through what is called a staging work-up.  In this we put the patient through a battery of tests that begin with the bone scan.  This is just an injection of a radioactive substance in the vein that travels to all the bones in your body.  The bone scan tells us the activity of the osteoblasts which, if you remember your high school anatomy, are the cells that lay down new bone.  When they do that they are reacting to prostate cancer, causing different sections of the scan to light up.  In this picture there is a suspect area at about L3.  This poor gentleman has some arthritis which, unfortunately lights up on a bone scan too.  He has arthritis in his shoulders in his lower tibia and in his ankles as well.  So, a body scan is not a very specific test  Unless you have a PSA above 10, you’re probably going to come back with a normal bone scan.

                ProstaScint is another scan we use.  It is basically a monoclonal antibody that goes to the cell surface antigen of the prostate gland cell and lights up.  But, again, ProstaScint scans are not by any means infallible.  We are a little discouraged by them, but if there is a local recurrence in the prostate bed (fossa), often times ProstaScint highlights it very nicely.

            Also, of course, we could do CT scans of the pelvis and abdomen as part of the work-up.  An MRI scan of your pelvis would probably show enlarged lymph nodes.  Finally, in most cases, your urologist will say, “Mr. Jones, except for your PSA all these tests are normal.”  That is the typical story.  Then he will do a DRE on you and tell you he can’t feel anything in the prostatic fossa.  Or, he may say that there is a nub in a tissue he can put his finger on and wants to do a biopsy.  He may get a positive biopsy, but don’t count on it as it only happens about 5% of the time.  This is about the time I get involved in your case.

OK, Now What?

                Here is the dilemma.  We know you have persistent disease, but we can’t tell you where it is simply because our tests are not good enough.  So, how do we treat a patient when we don’t know where the cancer is?   

                This is the issue that I’ve come here to talk about.  This has been a real problem throughout urologic and radiologic journals for the past ten years.  Earlier this year, a study from Stevenson and Scardino [Ed. both of them heavy hitters as doctors specializing in prostate cancer.] addressed this issue.  They pulled together all the medical data on 500 radical prostatectomy patients from five medical centers.  Their goal was to try to define how to treat these people with a potential cure using radiation therapy.  

                Their conclusion, in summary, was:  An estimated 65% of men who have a recurrence will develop bone metastasis within 10 years in the absence of any salvage therapy.  The factors are a rapid PSA doubling time, a high-grade disease, meaning a Gleason Grade of 8, 9 or 10, which turns on another red light telling us we have to do something in a short period of time, if we’re going to do anything at all.  Lastly, the interval since the radical operation is very important too; the shorter the interval the more serious the disease.

Findings Translate Into A New Approach

                What they were trying to prove was what an isolated local recurrence was.  In other words, where the prostate is taken out, where the tumor has invaded out of the capsule, where there are a few cells left behind in the fossa, that is an isolated local recurrence.  That is the patient who is potentially curable with radiation therapy.  Up until several years ago, we didn't pay much attention to that.  When someone had a rising PSA we just said we were going to either watch them or put them on androgen blockage.  But, now we are backing away from that and becoming a bit more aggressive.  This paper and a similar one from Johns Hopkins are the ones that are blazing the trail. When you have this isolated PSA and all other tests are normal,  they  discovered  several things:

                #1 - 50 to 60% of the time, that disease is, in fact, localized with the prostate fossa.  It hasn’t gone anywhere, has not metastasized.  That is the time we go ahead and recommend radiation therapy.  What we’re really doing is treating that patient as though he had a virgin prostate cancer.  We are going to treat him as though he were a newly diagnosed prostate cancer patient and offer him radiation therapy all the way.   Obviously we can’t do a seed implant because there is no tissue there, so this is all done with external beam, the IMRT, a really elegant treatment.

                What are the results?  After five years of follow up with treated patients, patients with the worst possible prognosis including being out of surgery only six months, his PSA doubling every three months and high-grade tumor with a Gleason over 8, there was an 80% cure rate.  This is stunningly successful treatment.

                #2 - How long do you wait to treat?  Do you wait until the PSA is 2, 5, 10?  What they showed was that if you went ahead and treated this patient when he PSA was 2, or less, then the probability that he will be free of disease after five years is in the 70 to 80% range.  Basically, what we have done is converted a recurrent situation by using a primary treatment option.  The surgeon used primary treatment when he removed the gross tumor, but unwittingly left small bits around the capsule.  These cells continue to divide and live until they eventually register as a positive PSA.  That is the signal for us to go ahead and proceed with another salvage.

                The results are encouraging, but I have to be as objective as I can and tell you there is a downside to this.  And, that is we are going to treat some patients that have distant  metastases and they will not benefit from the treatment.  We don’t have the tests to differentiate localized disease from metastasis; that is just a given fact.

To Summarize.....

                The point that I want to leave with you this afternoon is that prostatectomy recurrence is not necessarily an incurable situation.  I think the minds of all of us are beginning to shift dramatically and what we want to see, after radiation, is that PSA of 2 go down and down and stay down.

                Let me recap what we are doing now with the management of this particular clinical problem.  Locally recurrent prostate cancer is a lot more common than we previously thought.  We used to think when it came back it was everywhere, but we were mistaken.  In general, salvage (someone will come up with a better word someday) radiation therapy has been under used.  It was given infrequently and most of the time it was given too late..  The early results, which I think are quite interesting, are that patients who are treated aggressively and in a timely manner, are escaping metastatic disease progression.

                Any questions?    

Is there any PSA level that presupposes the patient has metastatic disease present?

                The only answer I can come up with is we divide patients into three groups; low risk, intermediate risk and high risk.  People with a PSA greater than 20 are that group of patients  who  are  at  high  risk  for  already having metastatic disease.  

Please discuss recurrence after external beam radiation.

                Well, it certainly occurs.  Basically, we treat the patient the same as I described earlier, with a work-up, and probably it is negative.  The same question faces your physician again; where did your disease recur? Did you recur in your prostate gland (remember you still have one)?  Or is your recurrence a distant one in bone or lymph node? So, how do you manage the patient?  If you can reasonably prove that the recurrence is in the prostate gland only, which is very difficult to do, you could be a candidate for either a salvage prostatectomy or a seed implantation for a salvage procedure.

                Really, at this clinical crossroad it’s best to sit with the patient and jointly make a tough decision, telling him you don’t know where the recurrence is.  This is why Lupron is used because it is a systemic treatment; it goes everywhere.  Now, I don’t like to treat things that I’m not positive about.  It is very uncomfortable for me and it’s very academically and intellectually poor for the patient.  That’s my answer to your question.

Is it more difficult to detect a seed implant recurrence?

                That’s a good question  -- the answer is yes and I'll tell you why.  The thing that makes it difficult is that after both an external beam treatment and a seed implant treatment, your PSA almost never goes to zero, and we don’t expect it to.  The reason it doesn’t go to zero is because the radiation is killing malignant cells which are radiosensitive, but it doesn’t kill normal prostate tissue.  If it did, we would have a complication and an ulcer and a clinical disaster.

                What happens after external beam radiation or seed implant is your PSA drops, but not to zero.  It will bump up and down between 0.05, or maybe 0.75, but it never goes to zero because there is a sub population of normal prostate cells that are alive and well and they are manufacturing PSA antigen and it is being measured.  The real frustrating part for me and I’m sure every other radio therapist, is a phenomenon called PSA “bounce”.  

                About two and a half years after radiation therapy, you will see the PSA bounce up to 1.0 or 1.2.  For the last seven or eight years everybody thought we had a recurrence, so biopsies were the order of the day.  The trouble was, they couldn’t find any cancer.  We finally realized that PSA bounce is a normal clinical event after radiation therapy.  

I had a radical prostatectomy 16 years ago and did fine.  Lately, my PSA has been bouncing around and finally I had a routine chest xray which showed a nodule.  I had a needle biopsy of the lung nodule and it was prostate cancer.  Can this prostate cancer nodule in my lung be radiated?

                Yes it can.  If that is your only disease site I wouldn’t back away from it.  Yours is a case where we need better testing to more accurately find all the tumor locations.

How many cancer cells does it take to show up in the case of a ProstaScint scan in soft tissue during a bone scan?

We don’t have that number, but I am going to give you one anyhow.  I was reading up, getting ready for you guys today, and found someone who estimated 1,000,000 tumor cells.  If you had 1,000,000 prostate tumor cells, your PSA would be 0.0035.  So, that is 1x10⁶, right?  Do we have any math teachers here?  If we went to a billion cells, instead of a million, that would be 1 x 10⁹ , or a thousand times more, then your PSA would be 3.5.  That’s the best I can do.

                And, with that I thank you for being such a good audience and wish you well.

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                The December meeting was the traditional member appreciation luncheon which meant no program to report to you.  Instead, we bring you a portion of the Sun City Center, Florida’s recent newsletter reporting on a presentation by a urologist who specializes in performing prostatectomies using robotics equipment.  The details of this procedure were reported to you two years ago, and in this update we think you’ll find the history of it’s development interesting and informative.  Bringing you this report is Dr. Frank Mastandrea who operates chiefly at St. Joseph’s Hospital in Tampa where the equipment is set up.  This is his story:

                Good afternoon, I’m glad to be back here again to tell you more about Robotics Surgery and it’s application to prostate cancer.  It has an interesting background and comes from three different technologies that came together to make it happen.  MIT came up with the first part, the “Utah Hand”.  This mechanical hand could mimic the function of the human wrist and fingers as they picked up items and moved them about.  This was an initiative from the U. S. Government to develop a way to move radioactive material remotely without having the operator near the “hot” material -- hence a robotics hand operated remotely.  

                The second part of the coming together was the “Virtual Reality” TV system that allows you to feel like you’re working right there even if you’re remote from the operation. Since I can’t teleport you I can telepresence you with virtual reality.  Games like Flight Simulator are good at this.  

                And, the third part came from a little known government agency called DARPA, the Department of Advanced Research Projects Agency.  These guys are so good, every once in a while you hear about something  of their work, but most of what they do you never hear about, such as advanced weapons technology.  They’re on the cutting edge.

                DARPA further refined the Utah Hand and wanted to do something with it regarding wounds that soldiers incurred on the battlefield.  They were looking at the casualties during the Vietnam War and discovered that 1/3 died immediately of massive trauma, 1/3 died because they couldn’t get to a MASH unit fast enough to be saved, and 1/3 survived being transported to a MASH hospital and treated there.  And, that rate of survival turns out to be the same as it was during the Civil War!!

                All the medical advances therefore, were not getting out to the front line combat areas where they were needed.  So they  were  out to  create the MEDFAST system, which can be seen on Military.com., which would provide robotic surgery at the front line.  Basically, what they would do is put a robotic surgery unit in a tank or Bradley Fighting Vehicle and take it to the front lines where wounded soldiers could be treated immediately by skilled surgeons who were working the robot from a remote and safe site.

                It failed, and the reason why is the time-delay factor of about 200 to 300 milliseconds, which is maximum workable time from when the surgeon moves his control until the robot makes its move when directly connected.  But since a direct beam was needed and that couldn’t occur except via satellite, the time delay increased to 1.2 seconds and that’s too long a delay for the operator to be accurate in his work and feedback.  So, they took all this equipment that they’d developed and sold it to private industry to see if there was a civilian application and hence the appearance of several robotic systems.

                So, I will talk about the one I work with, the da Vinci System.  There’s also Neuromate, RoboDoc, and Aesop and Zeus, which are now part of da Vinci.  They first used this equipment to do microscopic plastic surgery, very fine detailed work.  At that same time, laparoscopy procedures came along and they got the idea they could put these “ports” (long thin tubes that are inserted into the body and carry the instruments for the robot’s work) to make this instrument longer and more functional inside the body.  That’s how the da Vinci System got started.  It was actually tested out in France first.  So, this is where we are now, and what’s ahead?

A Peek At The Future

                We’re going to have better instruments and most importantly, we will have better “sensory feedback” (meaning being able to “feel” as the instrument pushes up against tissues).  Now, we only have about 10% sensory feedback and more will definitely improve our surgical technique.  They are also working on giving us more computer control and less surgeon guidance -- and that’s interesting -- maybe they’ll have surgeons standing in the unemployment line.  This comes into play more in the neurosurgery where they can make very precise placement and operation of robotic tools inside the brain; where tiny distances are so critical. 

                We also anticipate integrating the robot with X-ray data whereby the machine can be guided by X-rays taken earlier or online -- again very specific guidance.  All this goes to making the surgery more precise and more sensitive to tissues that shouldn’t be cut while locating those that should.  It’s real progress.

                We look at the da Vinci as an evolution of technology;

where has it been, where is it now and where is it going?  The first prostate surgery was “open” meaning we cut a big incision in the abdomen and worked around some very difficult organ systems.  Next, came more minimally invasive surgery -- laparoscopy, which was started by some gynecologists who used the laparoscopy to reattach fallopian tubes of women who had had prior tubal ligations and now wanted to have children.

                Then they discovered they could do gall bladder surgery with laparoscopes as well.  So, for 30 or 40 years, the laparoscope sat around and then suddenly something clicked and off it took.  Now the 3rd generation, robotic surgery comes along and I really think it’s an advance.

                Why?  It gives less pain, less discomfort, less trauma to the body.  Instead of big incisions half way down your belly, we can make just five little puncture wounds where we insert our ports.  We see much less blood loss and less need for and risk from blood transfusions.  Post operatively, the body handles puncture wounds much better than it does long slits, thus making more awful wounds, more pain and more blood loss.  

                We see definitely, with robotic surgery, less risk of infection, a much shorter hospital stay and less scarring.  And, return to work can happen much sooner with robotic surgery for prostate cancer.  I can get men back to work in two weeks with this surgery and have had them return in as little as a week.  You can’t match that with open prostate surgery, no way.  I’ve operated on a wide span of ages including a 70 year old man, which I would never have done with open surgery.

Here’s My Record, My Score Card

                I now have data on 94, cases though I’ve done over 150.  We had to convert to open surgery only once --- that’s a good record.  My demographics show the average age is about 60, I have 7 less than 50, and 7 that were 70 to 79 years old.  While we like to get as healthy a patient as we can, we still have  “co-morbid” cases meaning patients who have hypertension, diabetes, and are overweight.  You know, only 16% of my patients are in the normal body-index weight range -- that tells you something about our current society.

            I have to tell you that I prefer this robotic surgery over open surgery on heavy patients.  There robotic instruments bypass the fat; I can just put the instruments in and operate.  I don’t have to worry about that big fat pad of up to 5 or 6 inches.  And, that long open wound lends itself to infection -- just too much dead space.  We have a very low rate of infection, in fact the only infection we got was in a gentleman over 350 pounds.

                [Ed.  I hope you found that as interesting as I did.  We’re on the threshold of a whole new science in giving medical care and it’s fascinating to watch it unfold.]

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            There’s been a lot of criticism lately about the PSA test not being “specific” enough.  Despite that it has dropped the death rate of prostate cancer dramatically since 1988, researchers have been looking for something better.  Perhaps this article from the National Prostate Cancer Coalition last fall will prove new biomarkers are more accurate than PSA.

                ANN ARBOR, Mich. -- Researchers at the University

of Michigan Comprehensive Cancer Center have identified a panel of 22 biomarkers that together provide a more accurate screening for prostate cancer than the current prostate specific antigen, or PSA, test.  The study appears in the Sept. 22 issue of the New England Journal of Medicine.

                Current screening methods involve a blood test to check for prostate specific antigen, an enzyme produced by the prostate.  But the PSA test is controversial as a high level does not always indicate cancer, and some experts suggest a rise in PSA is more significant than a consistently high PSA.  A high PSA can also be indicative of benign prostate conditions.

                Initially, this new test could be used as a supplement to PSA.  A physician might suggest a patient with an elevated PSA have this test before a biopsy to better determine whether it’s a cancerous or benign condition.  In the future, it’s possible this could replace the PSA test.

                In the current study, researchers first tested the blood serum samples of 39 men with prostate cancer and 21 controls to identify autoantibodies against prostate cancer.  Cancer patients produce antibodies that fight against proteins that play a role in cancer.  The researchers scanned 2,300 autoantibodies and initially narrowed it down to 186 that reacted with blood serum from the men with prostate cancer.

                This discovery phase formed the basis for the next round of tests, in which 59 prostate cancer samples and 70 control samples were tested against the 186 autoantibodies.  In this phase, the researchers identified a panel of 22 compounds that best distinguished the prostate cancer blood samples from the controls.  Using these 22 markers, only two of 70 controls incorrectly tested positive for prostate cancer, and seven of 59 prostate cancer samples were falsely negative.

                Next, the researchers validated their findings using the remaining 128 blood serum samples.  They found eight of 68 controls and 11 of 60 prostate cancer samples were misclassified.  This means 88% of the time, samples that were not cancerous were correctly identified and 82% of the time, samples that were cancerous tested positive.

                The tests proved to be more reliable at predicting cancer than prostate specific antigen, which is a single biomarker.  PSA testing results in a false positive around 80% of the time, leading to unnecessary prostate biopsies.  The normal range for the PSA test is less than 4 in most men.  For men over 40 years old with a family history of prostate disease or for African-American men over 40, some doctors suggest that a level higher than 2.5 should be checked with more tests, because of they are at higher risk.

                The 22-biomarker test was reliable at identifying prostate cancer even in PSA ranges down to 2.5, scores which do not always suggest cancer.  The new test requires only a routine blood draw.  Most blood processing laboratories could easily be equipped to scan for these 22 biomarkers.  Researchers are conducting further studies to validate the findings with a larger, community-based group of patients.

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Adieu and Farewell

                This issue marks the final one edited and produced by the staff which has been with you sporadically from 1990 and consistently for the past  seven or eight years.  In that time we have been pleased to receive from our readers, many tributes for our clarity, accuracy and timeliness.  These have been treasured and, if you were one who wrote, you made our volunteer work most rewarding.

                As the sun sets on this group, we wish the new team every success in keeping the Man To Man - Sarasota newsletter a standard of truth, currency and a medium of trusted information.

                For myself as editor, I openly acknowledge the always necessary and most welcome proofreading of my wife and dear friend, Joan.  And, to Peter, for his wisdom, counsel and guidance over the years, my deepest thanks for both your patience,  professionalism and  cherished friendship.  

                To our readers, God Bless and keep you in good health.