In lieu of the reportage of the March meeting, we bring you a pot pourri of interesting and informative news about prostate cancer from various media. You had a right to expect to read about “ProstaScint Technology and Nuclear Medicine As It Relates to Prostate Cancer” as told by radiologist Dr. Robert McDonald. But, once again the recording facilities of Sarasota Memorial Hospital have let us down -- no tape for transcription. You’ll find these substitutions well worth reading:

Two revolutionary new drugs are in hospital pharmacies this week, a tangible sign that years of research into targeted approaches to fighting cancer are finally paying off, at least in a limited way. These new drugs are a far cry from the breakthrough that was predicted in 1998, when Nobel laureate James Watson was quoted as saying cancer would be cured “in two years” as a result of laboratory evidence that tumors would vanish if their blood supply was choked off.

Nevertheless, Avastin, approved by the U. S. Food and Drug Administration last week for treating advanced colon cancer, works precisely that way: It starves cancers by depriving them of the nutrients they need to grow and spread. A synthetic antibody developed by Genentech, Avastin was the second targeted cancer drug to be approved in two weeks. On Feb. 12, another antibody, Erbitux, won FDA clearance for a later stage of the same disease. (Erbitux, developed by ImClone Systems, is the drug at the heart of the Martha Stewart stock-trading scandal.)

“These drugs add to the growing list of new, specifically targeted treatments that are effective, less toxic and useful in a host of different cancers”, said Dr. Robert Mayer of Boston’s Dana-Farber Cancer Institute. “None of this was here five years ago. It’s incredibly exciting.”

The two drugs, and numerous others approved or in development, are part of a sea change made possible by new insights into the molecular biology of cancer. Unlike conventional cancer drugs, which kill normal cells along with cancerous ones and have toxic side effects, the new drugs are designed to block specific cellular mechanisms that promote cancer. The hope for drugs such as Avastin and Erbitux is that they will be able to destroy the cancer while sparing the body’s normal systems. Patients taking targeted drugs typically do not suffer the hair loss, stomach upset, mouth sores and loss of infection-fighting white blood cells that are the hallmark of conventional therapy.

Only one new drug has been able to cure cancer patients on its own. That drug, Gleevec, was designed to attack a mutant protein found almost exclusively in patients with chronic myeloid leukemia. But most other cancers - especially the big killers, such as breast, prostate, colon and lung cancer - involve numerous mutations. Scientists now believe that targeting any single genetic abnormality won’t be enough and that the main role of the new drugs will be in combination with other agents. Scientific thinking now is to try to turn cancer into a chronic disease and to have people live better and longer.

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A powerful antioxidant found in green tea may be responsible for the beverage’s heralded anticancer benefits. New research shows that the antioxidant, known as EGCG, binds to a protein found on tumor cells and dramatically slows their growth. Researchers say previous studies have shown that green tea helps protect against a variety of cancers, such as lung, prostate, and breast, but the mechanisms for these effects are not known.

In the study, published in April’s issue of NATURE STRUCTURAL & MOLECULAR BIOLOGY, researchers identified a potential target for the anti-tumor action of EGCG on human lung cancer cells that inhibited cancer cells’ growth. By learning more about this target, researchers may by able to develop new treatments that maximize green tea’s cancer-fighting potential.

In order to better understand how the antioxidants found in green tea may protect against cancer, researchers looked at how they affected a protein found on the surface of cancer cells called laminin receptor. This study showed that when the cancer cells with this protein were treated with polyphenol EGCG, the growth of the tumor cells was significantly reduced.

Researchers say the concentration of the antioxidant required to produce these anticancer effects was equivalent to those found in the body after drinking only two to three cups of green tea. Other components found in green tea, including caffeine, had no effect on tumor cell growth. Researchers say the results further the understanding of how antioxidants interact with cancer cells and may one day lead to more effective cancer therapies that use green tea as a dietary cancer treatment.

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The topic below is always a popular one that has many answers at our meetings, but not all of them work. If you’re a sufferer, take heart, and read on:

As more and more men are being treated for prostate cancer with hormone therapy, they’re experiencing an unusual side effect -- hot flashes. Now, a new study is testing an ancient therapy in the search for relief.

Joel Johnson is a retired electrician. When he started treatment for prostate cancer 8 years ago, he figured there would be side effects. He didn’t figure on hot flashes. “They seem to be a little like prickly heat on my face, and then just move on down the body, and I start sweating”, he said. It’s a sensation all too familiar to millions of menopausal women, and affects nearly 80 percent of men who receive hormone treatment to slow the growth of prostate cancers and make tumors shrink.

“With hormonal therapy, we lower the levels of the male hormone testosterone and men go through something very similar to menopause in women”, said Dr. Tomasz Beer, Research Director of the Oregon Health and Science University. Hot flashes can last from a few seconds to an hour. Mild ones are annoying. Severe ones can interfere with work and sleep. And, like women, men who suffer are finding that treatments aren’t very effective. That’s why a new clinical trial at Oregon Health and Science University is attracting attention.

“Well, there is a report from Sweden of trying acupuncture in a small group of men with prostate cancer that suggests that it’s helpful”, Beer said. The Swedish study found that acupuncture cut hot flashes by 70 percent at first and 50 percent after three months. The Oregon trial is the first in the nation to see if this ancient therapy can really turn down the heat. Johnson is optimistic, and despite six hot flashes a day, keeps his sense of humor.

“I had one woman tell me that every man should have hot flashes, so they know what women have to go through to please us”, Johnson said. Participants in the Oregon study will have 14 treatments over 10 weeks.

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In the last issue of this newsletter, there was an insert announcing the annual American Cancer Society’s Relay For Life celebration, and requesting a donation from you. We knew that our local readers would respond cheerfully, but what we didn’t expect was that those in faraway states would open their hearts and their wallets to us. Our gratitude knows no bounds for the large sums we have received from “the other 49”. Our deepest thanks for your generous response.

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Another step forward in the treatment of prostate cancer was picked up from a Canadian Internet site, THE MEDICAL POSTING, (www.medical posting.ca):

The future of cancer surgery may be a knife that never breaks the skin. It’s called “high intensity focused ultrasound”, or HIFU. It has been useful in treating prostate cancer and is being tested in kidney and liver cancers. “You can treat tumors deep within the body without needing to do any surgery and you don’t damage any of the tissue between the tumor and the skin surface,” says Dr. Gail ter Haar, head of therapeuitic ultrasound at Royal Marsden Hospital in London.

The procedure which uses high-powered ultrasound pulses to heat tissue, is being tested in patients with liver and kidney cancers. The results in early clinical trials are “exciting” ter Haar says. “It’s not yet a cure for cancer, but we’re going that way.” The technique uses normal diagnostic ultrasound to guide the focused beam of high-energy sound to the tumor. Just as the beam of light through a magnifying glass only burns objects at the point of focus, there’s no effect on tissue that isn’t at the focus of sound waves. The temperature of the tissue at the focus is greater than 60 degrees Celsius [140º F] -- enough to kill cells instantly. By “painting” the tumor with repeated bursts of sound, the entire cancer can be destroyed.

Compared with radiation and chemotherapy, the technique is free of side effects and can be used repeatedly with no concern about toxicity, ter Haar says. She says she expects her technique to be used widely within a few years.

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Researchers are busy in Utah looking at how cells communicate. This news comes from the May 2004 newsletter of Ron Koster’s Kingston PCa 101 group:

By studying how cancer develops at the cell level, University of Utah researchers hope to find new places to aim future drugs. Glenn Prestwich, a professor of medicinal chemistry at Utah , has studied how lipids, or fats, are involved in sending signals that trigger cell growth. Researchers hope that disrupting instruction-carrying messages inside a cell can help fight cancer, asthma and other ailments.

“We need to find kinder, gentler targets for every disease,” said Prestwich during a Science at Breakfast talk last week sponsored by the U. of U. College of Science. Traditional cancer-fighting drugs kill cancerous cells, but they also inflict side-effects on patients, such as nausea and fatigue. Drugs designed to stop cancer cells from growing without killing them could offer more comfortable treatment options. Lipid-cell signaling could spark new ideas in treating not only cancer but for problems ranging from cardiovascular disease to diabetes.

“{Lipids} are involved in a lot of cell-signaling processes,” said C. Dale Pouter, a U. of U. chemist who works with Prestwich. Part of Prestwich’s research focuses on a lipid known as PIP3. This lipid is involved in normal cell growth, but when present in great numbers, the cell grows out of control. This unregulated cell growth is the basis of many types of cancer.

An enzyme called PI3-Kinase is an important player in cells creating PIP3 lipids. By designing drugs that stop PIP3-Kinase from doing its job, fewer PIP3 lipids would be produced, which in turn would help slow unwanted cell growth, Prestwich said. Researchers are also looking at other steps involved in the cascade of actions that combine to form cancer, he said. There may be many steps in these complex chain reactions that could be disrupted using future drugs. These drugs would probably be part of a combination with traditional cancer-fighting therapies. Signal-disrupting drugs could weaken a cell to allow existing cancer drugs to work better. And, today’s cancer drugs could be used at lower doses when combined with future drugs that might result from this line of research.

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Something encouraging for those with heart disease who still have those romantic urges -- this article could bring a smile to your face. Quoted from the Internet website of MEDSCAPE Medical News {www.medscape.com}:

March 9, 2004 -- Sildenafil (Viagra) is safe for treatment of erectile dysfunction (ED) in some patients with New York Heart Association (NYHA) class II and II heart failure, according to the results of a randomized, double-blind, crossover trial published in the March 8 issue of the Archives of Internal Medicine.

“ED is common in patients with congestive heart failure (CHF) and is associated with symptoms of depression,” writes researchers from the University of Alberta in Edmonton, Canada. “Although Viagra is effective in treating ED, its use is considered a relative contraindication in CHF. Despite the high incidence of ED in patients with CHF, the effectiveness and the impact of ED treatment in this patient population are not known.”

In this prospective 12-week trial, 35 men with CHF and chronic ED were randomized to Viagra for six weeks followed by a placebo for six weeks, or to six weeks of each treatment in reverse order. Exclusion criteria were nitrate use and ischemia [Ed. local deficiency of blood supply] on exercise stress test or nuclear perfusion exam. Although Viagra caused a measurable blood pressure decrease, no patient had symptomatic hypotension [Ed. low blood pressure] or other adverse effects. Compared with the placebo, Viagra improved patients erectile abilities, eased their depression and improved their quality of life.

The authors recommend complete baseline safety measurements to ensure adequate physical fitness for sexual activity and absence of myocardial ischemia which would require nitrates. “The major finding of this study is that Viagra is safe and effective in treating ED in men with moderate heart failure who undergo appropriate screening,” the authors wrote. “Although the use of Viagra in patients with CHF at present is considered a relative contraindication, our findings suggest that this drug can be prescribed in patients with moderately severe CHF, provided that they are not taking nitrates and they have no evidence of low blood pressure.”

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This last item, of interest to those with lingering disease after treatment, is excerpted from a Reuters Health Information dispatch carried by Medscape.

NEW YORK - March 10, 2004. Second- and third-line antiandrogen therapy can be effective after prostate cancer relapses, according to a report in February issue of The Journal of Urology.

Most patients with advanced prostate cancer relapse after first-line maximum androgen blockade (Lupron or Zoladex), the authors explain, but apparent androgen independence does not necessarily mean that the tumor is resistant to further antiandrogen manipulation. Researchers in Chiba, Japan studied the efficacy of second- or third-line non steroidal antiandrogen therapy {flutamide [Eulexin] or bicalutamide [Casodex]} in 70 patients with advanced prostate cancer that relapsed after primary hormonal therapy.

Overall, the authors report, 40 percent of the patients treated with second-line non steroidal antiandrogen therapy and 29 percent of the patients treated with third-line non steroidal antiandrogen therapy showed a positive PSA response after changing antiandrogen drugs. Five-year survival of second-line responders (92 percent) was significantly better than that of non responders (24 percent), the report indicates.

Second-line responders showed a trend to lower pretreatment serum PSA levels and longer first-line therapy responses than did non responders, although the differences did not reach statistical significance.

“We would like to emphasize the clinical benefit of alternative antiandrogen therapy,” the report concluded. About half of those with hormone-refractory cancers responded to the therapy without significant side effects, whereas most patients who receive chemotherapy develop side effects, such as bone marrow suppression, nausea and vomiting.

The study is currently being expanded to a larger population to clarify what clinical features offer the best prognostic factors for hormonally treated prostate cancer patients.

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Our April speaker was not a medical professional, but rather a marketing type from a laboratory that specializes in prostate cancer and bladder cancer biopsy evaluations. His presentation covered what goes on in a laboratory and a glimpse into the future of testing. Here’s Mr. Edward Farley from Bostwick Laboratories.

Good afternoon. What we’re going to go over today is how biopsies are performed and how the specimens are tested. After that we’ll get into some new testing concepts and what the future may hold.

As you all know, the likelihood of being diagnosed with prostate cancer increases with age. The older you get, the more susceptible you are to coming down with the disease. In fact, men over 80 almost universally have a trace of prostate cancer which shows up frequently in postmortem autopsies.

Let’s find out what the prostate does; what is it for? (He gathers answers from several sources in the audience.) Correct. It produces seminal fluid to carry the sperm. How does prostate cancer start? Initially, it starts with inflammation, swelling of the prostate, and the unique environment. And, time is a big factor too, because the longer the disease progresses the more intensified it can get. Oxidative stress decreases your immune response to diseases like prostate cancer.

This is what a prostate looks like; walnut shaped with two sides, the base and an apex. This is what prostate cancer looks like; this slide was made from a prostate after an autopsy. You can see the area of concern here and definitely some in the peripheral areas too.

How do we find out whether a person has prostate cancer or not? You’re probably all familiar with the various tests like PSA and digital rectal exams and biopsies. It’s the latter, the biopsy procedure, that we’re going to talk about. That is the only truly definitive way that a physician can be sure of a diagnosis. There is a new urine test for prostate cancer that we’re going to talk about later today as well.

As you know, prostate cancer is being detected much earlier these days and patients are much better educated in the several options that may be available for treatment. As a result, better survival results are beginning to show up in national statistics. Man To Man programs are one excellent way for men to enhance their understanding of this disease. You are to be commended for being here today.

Sir, that’s the nature of the prostate specific antigen test and your results aren’t unique. PSA tests catch a lot of patients who potentially may have prostate cancer. If you’re in that group with a high PSA, there is a good chance that you may have prostate cancer. But, there is always a fair amount in that group that don’t have the disease. In effect, the PSA over-catches potential prostate cancer cases.

The opposite is true for bladder cancer testing. The test for bladder cancer is great at catching patients with the disease, but it misses some. And, that can be a big problem.

Back to talking about biopsies. When a physician is faced with a patient that he suspects may have prostate cancer, he plans on doing a biopsy. He must make a plan of how, where and how many biopsies he will take. He figuratively makes a map and inserts an ultrasound probe in the patient’s rectum which projects an image on a screen much like a television picture. Thus the physician can guide the biopsy needle to wherever he feels is the most suspect part of the prostate. With the addition now of Color Flow Doppler, the physician can identify “hot areas” where he can take more tissue samples. It’s a better system than standard ultrasound.

More than one; it can be six, twelve and sometimes physicians take more. [Ed. note: Readers will recall that our Dr. Barzell in describing his unique 3-D saturation mapping technique last November, said he took as many as 80 biopsies at one time.] The trick is how the physician labels them; where they were taken from is very important in recording where the cancer is.

A lot of physicians will take specimens from one side or both sides and say they are from the left, or right, which is less detailed than labeling them from the right apex or left base. More specific information gives the laboratory the ability to map out where the disease is once the report is developed.

Many times they are, as this is one way of checking to see if the treatment was successful.

Post biopsy adverse reactions can run a wide range although most biopsies are event-free. Some people say they didn’t know it was going on; some say it stung slightly; some say it was more painful than they thought it would be.

One adverse reaction is the possibility of infection. The physician may prescribe, either before or after the procedure, antibiotics as a precautionary measure. For up to a month afterward, there may be bleeding in the stools, the urine or in the semen. This not unusual. You will be advised to avoid strenuous procedures after the biopsy and it’s a good idea to drink a lot of water. If you come down with a fever nausea, vomiting, chills or shaking, you should contact your doctor immediately. The doctor should also be called if there is an inability to urinate when you feel the bladder is full.

What happens to the biopsy once that spring-loaded needle goes into the prostate for a split second and pulls out a core of tissue? First, they are put into a little jar that contains Formalin, a preservative. There should be as many of these jars ready, and properly labeled, for each biopsy the physician has planned to take. Some doctors use a grid system, like those on a map, which will help them interpret the laboratory report when it is received. Each of the jars is then sealed, placed in a box and ready to be picked up by the lab.

At the laboratory, the samples are prepared for the pathologist by baking and placing on a slide. A laboratory pathologist will probably look at as many as 100 slides a day under his microscope and record his findings using the Gleason Score which you are all familiar with. All laboratories have working agreements with similar facilities in the event that a second opinion is asked for. Those labs include Johns Hopkins, the US Air Force, the Moffitt Cancer Center here in Tampa and Sloan-Kettering in New York City.

Laboratory results are usually finished in a day or two Where the samples test positive for cancer, a Gleason Grade will be noted and in the case of PIN [Ed. Prostate Intraductal Neoplasia, a precancerous condition.] this too will be reported. “Suspicious” is another possible call, and although no one likes to use it, this is the case on occasion. This is where the colleagues at other locations [Ed. see paragraph above] come into play. Second opinions are sometimes asked of our fellow professionals.

Most biopsies are done transrectally, but there is another path by which the physician can go and this is through the perineum [Ed. that’s the small area between the scrotum and the anus.] There is another option, or will be soon, and I’ll be describing the new urine test in a few minutes. Everybody has to keep in mind that the only way a physician can definitively diagnose prostate cancer is via a biopsy.

The good thing about saturation biopsies is they get the cores closer together than normal. That means there is more potential of finding cancer because they are looking in small areas. It also enables the laboratory to definitively locate where the cancer is in the prostate if the samples are labeled properly.

Well, let’s go around the room and ask a few questions. How many have had three biopsies? A see several. How many have had four? There are two. And, here’s one man that has had five; that’s a lot. One thing about multiple biopsies and a large number of cores each time, is that they may have treated the disease by just taking out so much of the tissue. It does happen.

The answer is, we really don’t know. There is some school of thought that the more biopsies you do, the more you disrupt the tissue in the prostate, the stronger the possibility that the damaged tissue could become cancerous. This has not been proven by data, but it is a philosophy that a lot of physicians work with.

On the urine topic. Will it become a replacement for biopsies? No. At least at this point. Maybe some day. It’s something that a lot of work is being done on and we’re looking forward to it with great expectations.

Also, another promising new lead in prostate cancer is the UMP-3 Test, the first genetic test for prostate cancer. This is an RNA-based test, as opposed to a DNA-based test such as the ploidy test of years ago which identified the intensity of prostate cancer. Using RNA, researchers are looking for a specific gene that can be found only in the prostate. It can’t be found in a hair sample or saliva.

There is some medical news that the test is producing some positive results. The gene they are looking for is the PCA-3 gene, which is proved to be prominent in prostate cancer patients. If a man is found to have this gene, then there is a pretty certain chance that he will, if not already, be diagnosed with prostate cancer.

The methodology of obtaining a sample is the physician massages the patient’s prostate as though doing an DRE, which produces some secretions in the urethra. Then, the patient urinates into a sample container and the test is done on that. The laboratory test result is expressed as either a “yes” or “no”, meaning the gene is present or it is not. So far, in testing almost 1,000 patients worldwide, almost 90% of the men who have that gene will have a positive biopsy..

The UMP-3 test and the PCA-3 gene detection are being debated how they are to be utilized. There are many potential avenues. Obviously, patients with high-rising PSAs who have had multiple negative biopsies are prime candidates. It is not supposed to replace biopsies or PSA. Those are great tests and they are still going to be used. This is an additional accentuator to help detect prostate cancer.

I hope you enjoyed this presentation. Thank you for inviting me.

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As late as this message is, we hope that all of you snowbirds have filed changes of address with us. If you came to a meeting, we probably know where you’ll be for the next several months, but if didn’t fill out a change notice, and a good hearted friend has forwarded this to you, it’s not too late to send us note and tell us where to find you.

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We Sarasotans have always been proud of our hospital, Sarasota Memorial Hospital. It consistently ranks in the top 10% of community hospitals in the country and recently it gained even further eminence with this announcement. (Courtesy of the CORINTHIAN, a publication by Sarasota Memorial Healthcare Foundation, Inc.)

An evolution in the treatment of cancer is making it unnecessary for the vast majority of cancer patients in Sarasota to seek care outside of the area.

“We have made dramatic advancements in the quality of personnel and technology at Sarasota Memorial Hospital and in the community medical practices,” related Richard H. Brown, MD, Medical Director of SHM’s Cancer Care Services.

“The quality of the surgical, radiation and medical oncology, as well as the supportive care, is first rate and getting better all the time. In many respects, our treatment is as good as that delivered in many national cancer centers,” he added.

Except in rare instances, leaving town to seek cancer care has become pointless. According to Dr. Brown, most cancer care is being delivered in community settings rather than specialized centers.

Sheer volume is driving much of that trend.

In Sarasota, as it is nationwide, cancer is the #2 leading cause of death. In the next decade, it is expected to surpass heart disease as the #1 killer. Cancer is an age-related illness in an aging population, and the demand for local treatment is only going to increase.

“We are seeing about 2,500 new cancer patients a year at SMH alone,” Dr. Brown said. “That is more than some states see altogether. With few exceptions, we treat all of those cases here. It is better for patients to get care locally, near their homes and families. There is a tendency for patients to get scared and want to go to the best place. The good news is, you don’t have to look farther than SMH to find it,” he added.

SMH has received awards for Employer of Year from the Oncology Nurses Association for their commitment to oncology nurses education. More than half the nurses on SMH’s Cancer Care floor are oncology certified. The hospital has won awards for its cancer registry that tracks every diagnosis, treatment and outcome.

SMH Cancer Care Services professionalism has been verified with unconditional accreditation by the American College of Surgeons Commission on Cancer.

“We are blessed to live in a community where we are afforded the level of technology, personnel, resources and the commitment of a hospital administration that usually is seen only in larger medical centers,” Dr. Brown noted.

Despite the increase in the number of cancer patients, people are living longer with the disease. Better diagnostic tools, such as digital mammography and treatments, are resulting in outright cures or better prevention of recurrences. Increasingly, cancer is being viewed as a chronic condition that can be managed for long periods of time, rather than a fatal one.