The speaker for the March 20th meeting was Gerry Andriole, MD. Introduced by colleague and friend Alan Treiman, MD, Dr. Andriole went to Penn State Medical School and served his residency in surgery at Rochester Strong Memorial. He served as chief resident at Brigham Hospital in Boston at the Harvard Program in Urology (which was started by Dr. Treiman). He has gone on to an illustrious career at Washington University in St. Louis, where he has built one of the foremost urology departments in the world. Dr. Andriole is considered to be one of the premier thinkers in urology. He is a talented surgeon, scientist and researcher with hundreds of papers, journal articles and book chapters. (The following is an edited version of Dr. Andriole’s lecture.)

Dr. Andriole: Thank you. It is very challenging to think of what to tell a group like this about prostate cancer. I thought the simplest thing to do is to cover four basic points: screening, prevention, treatment of localized disease that hasn’t spread, and treatment of advanced or recurrent prostate cancer. We have been screening for prostate cancer with PSA now for about 15 years. There has been nothing like it in the annuals of oncology ever before. A recent study from Toronto, Canada showing that if you are a young man and you got screened for prostate cancer you reduce by about 50% your lifetime risk of being diagnosed with metastatic prostate cancer. There is no other disease that has a screening tool that is as good as PSA. And, I would say that nationally we have almost eliminated metastatic disease as a presentation for prostate cancer. 

When we started with PSA in 1987 we said if the PSA is between 4 and 10, get a biopsy. If we did a radical prostatectomy on you, the unfortunate news was that about 60% of the time, we found microscopically advanced prostate cancer. Now we have been screening a population of men as recently as the year 2000 we have reduced even the incidence of micro-metastatic disease by about 50% down to about 25% overall. This is a very profound so called pathological stage migration.

We really don’t know if we are saving lives with PSA screening now, but there is very, very strong accumulating evidence that if a man undergoes screening with PSA for prostate cancer and he is eligible and he undergoes a radical prostatectomy, we are going to substantially impact the mortality of this disease. There are three really good studies, one in Scandinavia, one in the Tyrol part of Austria, and the National Cancer Institute studies.

The mortality rate for prostate cancer for black men and white men in the United States peaked in 1993 and has been steadily declining ever since. In the Tyrol area in Austria, men are required to get a PSA at age 50 and if you have prostate cancer nearly 95% of the men get a radical prostatectomy. And since they’ve implemented that program in the early 1990’s, mortality rates for prostate cancer have gone down. The mortality rate for prostate cancer in the other parts of Austria has really not changed. And, that is really, really solid first line evidence that screening and radical prostatectomy works.

Just a few months ago the New England Journal of Medicine showed unambiguously that radical prostatectomy cures prostate cancer and that men who undergo radical prostatectomy in comparison to men who do watchful waiting have about a 45% reduced rate of dying of prostate cancer.

That is what PSA has done so far. But, are we using PSA properly? We are not! The reason is we’ve been tricked by what’s called the verification bias. So somebody …Gerald Murphy, said the higher your PSA is the more likely you are to have prostate cancer. He proposed the PSA cut point of ten. About fifteen years ago we lowered the cut point to four. About four years ago in our studies at Washington University we lowered it to 2.5. And, we’ve only been performing biopsies on men who have a PSA higher than those numbers over the years. Turns out that’s not right. Now I would say if a man is less than 60 years of age the cut point should be 1.4. There’s a lot of statistics to back that up. For men over the age of 60 the cut point should be 2.1. This is substantially different from what we’ve been thinking about this disease for the last several years.

There was a prostate cancer prevention trial published a year or so ago in the New England Journal of Medicine, which said if men with PSA values in the .6 to 1.0 range and their PSA didn’t change for 7 years, if they had a biopsy of the prostate 10% of them had prostate cancer. If their PSA was 1.1 to 2.0 (17%), 2.1 (24%). So really, waiting for the PSA to get over 4.0, as we traditionally thought, is possibly too late in the game. If you have any relatives with a family history of high risk prostate cancer, they really ought to think about using a lower cut point for their PSA.

The other thing we have to pay attention to is what is called PSA velocity – the rate of the PSA change. If a man’s PSA rises by 2 points in the year prior to the diagnosis of prostate cancer, he has a lethal form of the disease. One of the studies I am doing for the National Cancer Institute is called “Randomized Screening Trial.” We have 38,350 men who get screened every year for their PSA. And, we have another 38,350 men who don’t get screened. We’re going to compare what the exact difference in mortality is between the men who get screened and the men who don’t.

If you are in the PLCO study and your PSA rose by more than 2.0 points in the year prior to the diagnosis of your cancer, you are much more likely to have a more aggressive prostate cancer. I’m not saying that PSA rises greater than 2.0 is what we ought to wait for. Maybe we should use a PSA velocity cut point that is lower than that. If my PSA was rising more than a point or a point and a half per year I would have a biopsy no matter what my PSA threshold was. 

Obesity can make a lot of cancers worse. Prostate cancer is probably no exception. The higher the BMI (Body Mass Index), the fatter you are. Heavier men have lower PSAs than skinnier men. So, whatever threshold for biopsy that you are talking about in a skinny man, you’ve got to lower that threshold for men who are substantially overweight. Of men who get prostate cancer, a high BMI was statistically almost as important as their overall PSA and their rectal exam or even race to predict prostate cancer. Furthermore, the higher your BMI, the more likely you are to be diagnosed with at least Gleason 7, 8 or 9.

How about prevention? There are a lot of different agents out there; one of the most promising is Finasteride, which reduces the level of the bad form of testosterone, dihydrotestosterone, in the prostate. One of the studies that I’m doing now is a prostate cancer prevention trial using the drug Dutasteride, which is more potent than Finasteride. Dutasteride is marketed as Avodart, approved for BPH. How is it better? There are two types of the enzyme and Finasteride only inhibits one of them. Dutasteride inhibits both of the forms. It reduces the bad form of the male hormone dihydrotestosterone by 93% compared to Finasteride, which only reduces it by 70%. It reduces the amount of this bad hormone in your prostate by essentially 100%, and it has a longer half-life.

We sent our slides to an independent third reviewer and they showed that if you took Dutasteride prior to a radical prostatectomy your tumor shrinks. That’s why we have enrolled 8200 men in a chemo prevention trial using Dutasteride. We ought to have the results of that study within the next 2 to 2-1/2 years. But, for now, if I wanted to prevent prostate cancer I would prefer to use Dutasteride than Finasteride.

The drug toremifene citrate is approved for breast cancer. But the 20 mg dose in one study showed that it reduced the overall incidence of cancer. So, if you are a man and you have a prostate biopsy that shows PIN, or prostatic intraepithelial neoplasia, you know that’s like a time bomb saying that you have a high chance of getting prostate cancer in the next several years. You might consider taking toremifene citrate.

Regarding treatment of localized disease, I’m an unabashed fan of laparoscopic radical prostatectomy. After having done 2500 open prostatectomies, I have given it up and for the last 3 or 4 years done about 600 laparoscopic radical prostatectomies because it harms less than an open prostatectomy. There’s also lots of data showing that your surgical margin rates, your overall survival, your continence, your potency, everything is the same.

The 3-D camera has made laparoscopic surgery easy and pleasant to do. As recently as 2 years ago laparoscopy was like looking at your TV, only in two dimensions. So this is a substantial innovation. It was really only about four or five years ago that the training programs were starting to turn out surgeons who knew how to do laparoscopic surgery. There are many terrific open surgeons, but the skills you know as an open surgeon don’t translate well to laparoscopy. You have to be retrained. There’s a new tool called the DaVinci robot or the so-called intuitive robot. A robotic prostatectomy is the same as laparoscopic prostatectomy except that the robotic arms are operating the tools that are moving inside the person’s body. The surgeon is sitting at a remote control station. This is going to be perfect for the next generation of surgeons. But, a laparoscopic prostatectomy and a robotic prostatectomy are equivalent. And, we are going to report that at upcoming meeting in terms of health related quality of life outcomes.

There are only two problems I see with the robot. It is expensive, costing $1.5 million. It costs you an extra $1500 to $2000 a case to use it. And, the other thing is that you lose a little bit of your tactile feedback. When I’m doing surgery directly and my hand is on the instrument, I can feel whether I’m squeezing something that is hard or soft or supple. If you are operating a video game controller, the robotic arm is in there operating the forceps and the tweezers. You have no idea what you’re doing. That’s something worth thinking about. There are robotic companies trying to impart tactile information to make up for this.

Urologists are often criticized of over treatment of their prostate cancer patients. We’re all struggling to find what’s called a focal therapy. If you are elderly, with a tiny tumor, maybe we don’t need to take out your whole prostate, maybe we can ablate. Just destroy the cancer in your prostate. There’s emerging data on some of these experimental techniques, the one I am most interested in is called the ToCad technique, which is really photo-dynamic therapy. And, actually it’s a cholesterol derivative injected I.V. This really isn’t ready for prime time, but we are working on it.

Regarding the treatment of recurrent prostate cancer, unhappily surgery does not work every time, nor radiation, nor all of these fancy laser based ablations. Hormone therapy was recognized in the 1950’s to be an effective form of treatment for prostate cancer. We know that men treated with early hormonal therapy do better than men treated with late hormonal therapy. So, we can’t throw hormone therapy out.

There are some bad things about hormone therapy. It washes your bones out and makes you feel lousy. There are some issues of intermittent therapy verses continuous. But it’s a pretty good bang for the buck, although it’s often not good enough.

Finally there is an improved form of chemotherapy for prostate cancer. Men who have generally failed hormonal therapy who receive Docetaxel, Taxol-based chemotherapy, have improved survival in comparison to men who don’t. It’s two months improvement on average. It doesn’t sound like a lot but actually there are some men who lived for a year or two longer than that. One of the things that I like is immunotherapy for recurrent prostate cancer, and the vaccine Provenge shows a substantial, sustained prolonged reduction in PSA levels. The FDA says “prove to me that that means they’re going to live longer”. Well, that’s going to take some time. But if you can control the PSA levels, meaning the only thing that makes PSA in a man who has had a radical prostatectomy is prostate cancer cells, and if you can cut down their production of PSA, you are probably killing some of the cancer cells at least. That should translate into a longer overall life expectancy.

So, in summary, I think that in 2006 we can say a few things. Number one, screening works and it will improve. You know there is a gene test coming out that is going to be looking at urine samples that may be complimentary to PSA. Secondly, prevention of prostate cancer is at least plausible. For treatment of localized disease, I think you should have a minimally invasive laparoscopic or robotic radical prostatectomy. It is far preferable to open. As a medical community we’ve got to find better ways to kill this disease, and I like the idea of focal ablation using either cryo or some form of laser energy.

Finally the treatment of recurrent disease -- hormone therapy is good. We will never forget hormone therapy. But, we know it’s not enough. Chemotherapy – we finally got one thing that seems to work, but it’s not a blockbuster. Hopefully though, immunotherapy is not too far behind and we can do that a little bit better. Having said that; thank you very much. I appreciate your attention.

What about Celebrex and Vioxx? There’s no question that inflammation is an important promoter of prostate cancer; as it is with other cancers. There’s this new entity out there called PIA. You might have had PIN. There’s a thing call proliferative inflammatory atrophy. If we turn on our inflammatory pathways where those little white cells in there are elaborating all sort of mitogens that are probably promoting more aggressive turnover of the prostatic cells. It’s thought to be important for cancer. That is why, until Vioxx got put off the market; another study that we were doing was a randomized comparison of Vioxx verses placebo in preventing prostate cancer.

We are doing a study with Celebrex in bladder cancer. But there are issues about how it gets into the prostate that may not make it the perfect prostate drug. Now with all of the data out there, maybe if you take these drugs you are doing something to your cardiovascular mortality. It may not be a net benefit to the patient. So, I wouldn’t recommend that personally. But, I do think there is some basic science to suggest that it could be somewhat important.

What about Lycopene? The Harvard School of Public Health has an enormous database from a study called the Physician’s Health Trial at Framingham, Massachusetts. It says that your intake of lycopene in cooked tomatoes lowers your overall occurrence rate of prostate cancer. And, that’s as much as anybody could say about it. It probably is helpful.

How do you distinguish non-metastatic or localized cancer from either advanced or metastatic prostate cancer?           The best two tests are MRI and PET, prostate emission tomography. We have a new isotope called C11 Acetate that is probably not available at your hospital because it is not yet approved by the FDA. But, we’ve been doing a study for the last two years using it as a staging tool. If you were on the cusp of not knowing or worrying whether you have micro-metastatic disease, you might consider calling around and trying to get a C11 Acetate PET Scan because there have certainly been cases where it has shown something that MRI and the other standard imaging tests have not. But, beyond that, there is nothing beyond PET and MRI right now that I am aware of.

I read that the cure rates for radiation, seeds, and surgery is about the same. Will you explain that? What they are looking at is PSA control rates, not the same as preventing death. And the problem is, the average guy with prostate cancer isn’t going to die for many years. It’s hard to show that having a treatment reduces death from this disease. There’s only been the one study from Scandinavia that actually shows that anything prevents death from prostate cancer. That took 8.2 years of follow-up with something like 1900 patients. If you actually use the same rubric that the FDA uses to approve drugs for prostate cancer, which is show me a survival advantage, not a PSA benefit, but a survival advantage, the data are not there for radiation yet. Not to say it doesn’t do it, just to say the study hasn’t been organized in a way or published. It may be. But, it’s not out there, technically. And it wasn’t out there until recently for surgery.

What experiences have you had with laparoscopic prostatectomy for patients where external beam radiation has failed and is still localized? It’s challenging. The main reason   is that the radiation really induces some scaring on the outside of the prostate. In the guy who has not had radiation, you can meticulously dissect things out. In the guy who has had radiation, you are chiseling it out because there is so much fibrosis in there. At least for open surgery the incontinence rates are 50 to 60%. The impotence rates are 100%. The colostomy rate is about 3%. That’s because the rectum, you know, might be fused to the inter-surface of the prostate. It is not for the faint of heart.

What about watchful waiting? When I put patients on watchful waiting, I usually recommend a re-biopsy after a year or two. I want to see if the biopsy characteristics, a year or two later, are the same as the ones I found initially. I think that re-biopsies are to way to go. PSA is sort of a lagging indicator and if you wait for your PSA to go up 2 points it may be finished. I would personally recommend a repeat biopsy. There is a study starting in Canada where half of the men on watchful waiting are taking Dutasteride and half are getting a placebo. After a year or two on the biopsies, we will see who has more cancer. That’s another option you might consider. End

The speaker for the April 24, 2006 meeting was Don Kaltenbach, executive director of the Dattoli Cancer Center, a 15+ yr. survivor of prostate cancer and the author of numerous books on the subject. The following is an edited version of his lecture:

Don Kaltenbach: Let me ask a few questions first: How many of you folks are dealing with the issue of recurrence? There are quite a few. And, how many of you have had radical prostatectomy? How many of you just had external beam radiation alone? How many of you have had just seeding alone? How of you had had a combination of external beam and seeding (internal radiation)? Are there any folks with cryosurgery? Is there anyone with watchful waiting?

Let me make a few points first: I am not a doctor; I cannot give out medical advice; I can only be a messenger of information. I am associated with the Dattoli Cancer Center, and even though I strongly believe in what we do and how we do it and our commitment to doing it, I can assure you that I also strongly believe each man needs to get the facts and make their own decision. What I did doesn’t necessarily mean that is what you would or should do.

I personally am not dealing with the issue of recurrence. I was diagnosed with prostate cancer in 1990 at the age of 44. I had three little kids. As you know when you are diagnosed with cancer it knocks the wind out of you. For me, I went into my cave. I couldn’t tell my wife for over ten days that I had cancer. But that was part of the journey. I had Palladium-103 brachytherapy. It was really new at that time. I had 63 radioactive seeds by my very fine doctor Harold McDonald up in the Marietta, Georgia area. Unfortunately, Dr. McDonald died about 2-1/2 years after that. But it changed my life. I didn’t have the combination treatment; that didn’t exist back then. Hormonal therapy was still off in the sideline for me anyway. Over the years I have followed my PSA and it has come down to a 0.1, 0.2 and in that particular area.

We have the front side of treatment and we have the back side of treatment. The front side is, of course, is looking at options and fortunately today there are many, many options.

But what I have found, personally, and also have seen through our Cancer Center is the back side of treatment. And that is the fear factor of recurrence. Whenever I have a blood test taken for that purpose, I always pause and wonder, “Will this be the time? It has now been 15 years, eight months and eight days with a good reading. But, you wonder. So that is the fear factor.

What is recurrence? Recurrence is not new cancer; rather it is some of the initial cancer that was not successfully eliminated during the first treatment. In the meantime, what has happened is these microscopic cancers have had an opportunity to reorganize and get bigger. So at some point there’s going to be enough growth where they are detectable.

One of the problems that we have today is screening, even though it’s gotten better. Microscopic cancers still can be a problem. Sometimes when recurrence develops it may appear in some other area other than the prostate area. It may appear in the bones, the pelvis, spine, bladder, kidneys, and lymph nodes. So, those are the kind of areas where this can pop-up.

What are your chances of having recurrence? A lot can be decided right up front when you are first tested. Do you have small numbers? Or, do you have astronomical numbers? Do you have a PSA of 28 with a Gleason of 8? Then there is a greater likelihood that you are going to have some sort of recurrence. How much cancer do you have? Is it located in just one lobe, or both? How many biopsies were taken? How many were positive and what percentages? Then the type of procedure that you had comes into play.

There are certain procedures you obviously should not have if you want success. As an example, all early stage cancers where the cancers are truly confined to the prostate you can choose from many options and still have a good result. Such as radical prostatectomy, external beam, internal radiation, a combination of those; cryosurgery, hormonal therapy all those can give you the same result. But, there are certain points in time where they won’t. As an example again that big case of 28 on the PSA and a Gleason of 8; most likely that cancer is outside the prostate. Having radical prostatectomy with those numbers, you’re still going to have a failure. So, on the front side of treatment, it’s very, very important to use the legal term “due diligence.” If you have a heart attack you’ve got to go to the hospital right now. You don’t have time to dig around to find out who the best doctor is. But, with prostate cancer it is not something you got on Monday, you were diagnosed on Tuesday, and you must be treated on Wednesday. So, I encourage men to really look at options and make a wise and informed decision because that will help you on the back side of treatment in the event you have recurrence. And at least time is on our side in order to make these kinds of decisions.

How does prostate cancer reoccur? First of all, there are microscopic cells in the body and they want to grow. They are not going to die on their own. And, at some point they start multiplying even more. For a tumor to be recognized you need about a billion cancer cells in order to have that. So, it may be years before it shows up. Today with the current screening and testing, even though it’s gotten much better, certainly in the last 15 years that I have been involved with this, it’s still not perfect. There are some new technologies coming this way, one of which I spent several months looking at last year called spectroscopy. It is something that is tied in with MRI and it does work well for brain cancers, but they have not yet been able to make it work effectively for prostate cancers. I know Phillips and GE are both working on that in earnest, using an endorectal coil that does create some distortion. And they are now looking at a more powerful magnet. I foresee that maybe in the next couple of years we will have that.

The location of the prostate cancer residue can be basically in one of three general areas: 1) in the prostate itself, 2) in the prostate bed, or 3) in some other area of the body, some other organ or in the spine. Recurrence can be in three different areas: local recurrence, occurring within the prostate or prostate bed; the second type, perhaps the most common, is the PSA or called bio-chemical failure or bio-chemical recurrence. When there is a rising PSA but we can’t find the cancer. So, you go through the image studies like the bone scan, as an example, ProstaScint perhaps, CT scan. CT scans, by the way, are good for finding enlarged lymph nodes which may be an indication of prostate cancer. Anyway, you go through those tests and it’s not showing up but the PSA is rising.

The other type is called metastatic disease. This is where it has traveled to more distant organs, again, the bones, lymph nodes, lungs, bladder, and kidneys. But, generally, it will go to the pelvic area and to the spine first.

Another way to classify the cancer is to do it two ways; hormonal sensitive or hormonal naive. Hormonal sensitive means that your rising PSA will drop if you are on hormones. The other type, though, is hormonal refractory; which means it is somewhat immune or is immune to the hormones. What you want is the first choice. A lot of factors go into determining if you can kill the cancer or if you have to co-exist with it. If the cancer is still confined to the prostate or in one of those particular areas near by, it can be treated with radiation. If it is somewhere in the body and you don’t know where then radiation is not going to give you a cure, and you find yourself having to co-exist with the enemy.

Now, on the backside of treatment, what should we be on the lookout for in regards to recurrence? We recommend an ultra-sensitive PSA test, a relatively new type of test; third generation using a different way of analyzing the blood called chemoluminescence. So, instead of having a two-digit readout, you can have up to a four- or five-digit readout on an ultra-sensitive PSA. There is another test called PAP, (Prostatic Acid Phosphatase) which was around prior to the PSA. That was pushed off the table when the PSA came around. And, by the way, the PSA was approved by the FDA around ’95 or ’96 for monitoring purposes only, even though the PSA was somewhat used prior to that. We never stopped using the test and have found that it can be an independent prognosticator for treatment failure. I know when I was diagnosed in 1990 it was not through a PSA. I was diagnosed because I had blood in my urine.

So, we have the ultra-sensitive PSA and the PAP. If you had radiation you still have your gland. There can be a time, especially for younger men who have had external beam radiation and seeds, in about 20 months they will have a spike from prostatitis due to radiation. It has nothing to do with cancer returning. But, if you look at that PSA in relation to the other test called the PAP, that test should be very low. So, if you still have your gland you may have some variations from time to time with the PSA. But the PAP, if that is also staying low that is a good sign. We also strongly believe in a Color Flow Doppler. I’m sure many of you have heard of that now. You have seen Doppler radar on TV; especially during hurricane season. You know how thunderstorms stand out in red because there is more activity in a thunderstorm than the other surrounding areas. Cancer cells are the same way. They have a greater need for more blood in relation to the other surrounding tissue. So, on a Color Flow Doppler it measures that extra activity and those cancer tumors will stand out in red. There should be a difference between what your color flow looked like prior to treatment and what it should look like on the back side of treatment. Now of course if you have had a radical prostatectomy you are not going to see much. The CT scan is also useful, on an annual basis looking for any lymph node enlargement.

If at some point it looks like you may have a recurrence then more testing is required. And it’s really trying to nail down where this stuff is. Taking a biopsy may not be easy to do. But a bone scan would be a typical thing that you would do. A ProstaScint test looks for microscopic cancers. It is not 100% accurate; there is about a 25% error rate, but can help determine if you have recurrence. Perhaps a PET/CT scan can help. But then again what I see coming is a spectroscopy.

Who is at risk for recurrence? Those least likely to have recurrence are stages of T2a or less, a Gleason score between 2 and 6, and a PSA of 10 or less. An intermediate level would be any combination of two of those. Unfavorable would be any combination of three or more of those. So, if you had a T2c, a Gleason of 8, and a PSA of 15, that would be a signal for a high probability of recurrence.

For surgical patients, low risk guys with Gleason scores between 2 and 6, and PSAs of 10 or less, T2a, there is a 25% chance of recurrence. Medium risk guys of T2B’s, Gleasons of 7s, and PSA between 10-20, have a 25-50% chance. The high risk are guys of T2C’s, Gleasons of 8 to 10, PSA’s of 20+, who have a greater than 50% chance of failure. Those are based upon studies outside of our center.

If you’ve had failure following surgery one treatment option may be radiation. There is an independent study out now saying that radiation following surgery reduces your likelihood of recurrence. Hormonal therapy may also follow.  

If you have a failure following radiation, you will have hormonal therapy. It may be possible to have some additional radiation and/or seeding, it just depends on your situation. We’ve seen some cases where guys were seeded and they had a failure. And in looking at their CT scan, you can see that the whole prostate was not seeded. Only part of it was. In fact over the years there have been two cases where the gentlemen were seeded and not one seed got in the prostate. Somebody like that can have seeds and some IMRT. So, if there is still room to work with, it may be possible to get some external beam such as IMRT.  If you have had Palladium-103 seeding and had a failure, Dr. Dattoli is apt to give you another seed like Iodine-125, because its properties are a little bit different. Or, if you had Iodine-125 and a failure, then he will give you a Palladium-103.

Hormonal therapy will not cure your prostate cancer. You are living with the enemy, trying to control it. At Dattoli Cancer Center, if you’ve had a recurrence and we’ve looked at the radiation aspect, we may go on to the next step, commonly referred to as triple hormonal blockade consisting first of an injection, which could be Trelstar, Eligard or Lupron. The second one would be Casodex, a pill -- the idea there is to help block other pathways to the cancer. And another medication would be Avodart; originally designed to shrink the prostate for guys who have BPH, an enlarged prostate, which has nothing to do with prostate cancer. But it has certain properties which help control the recurrence.  Our protocol at the office would be that hormonal combination for 9 to 12 months. If your PSA comes down and stays down, then you have a “drug holiday” for at least a year. But every three months while you are on treatment you will have a blood workup, including an ultra-sensitive PSA and a PAP to see if there’s any change. If the PSA starts to rise, they will most likely use the same combination, but the time period won’t last as long. Rather than going for a year, they may only be able to go for 9 months, and then repeat that sequence. If that works, they will keep that up until that may not work anymore and then do the same thing for six months. It depends on the individual and the situation. If all that fails then the next line of defense would be a combination of anti-fungal drug, steroids, high doses of vitamin D or D3, perhaps dropping Casodex and then some bone agents to help with the bone integrity. That protocol may keep it under control. If that doesn’t work, then you need to see a hematological oncologist and look at chemotherapy. The drug of choice is Taxotere, probably with some other hormone drugs along with steroids. So that would be a great line of defense. Charles “Snuffy” Myers, MD is an expert in this field. Steven Strom is another physician who excels in that area. The organization PAC has doctors on their advisory panel that help in the topic of recurrence.

What we’ve seen at our center is if there is going to be a failure, 80% of the failures occur within two to three years, and the other 20% within six years of treatment. We feel strongly that if you have made it through six years; you should feel very, very comfortable.

If you are diagnosed with prostate cancer, does this mean you are going to die from it? Not necessarily. Does it mean you will have pain and discomfort? Not necessarily. Does it mean that you failed? No. It is just that all your cancer was not eliminated at the time, or it was located someplace else and was not findable, or (hopefully not) a poor treatment to begin with. Again, I feel you have to have a winning attitude on all of this, and that can be a struggle. I have known some men who have had to deal with this, but it has to be a “can do.” It is you against it, and you have to keep fighting. You can’t give up. And making prudent well-informed decisions can buy you a long time. If you have a recurrence and you do the right things to catch it quickly, you can go on for a lot longer. End

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Editor’s note: The complete transcripts of the preceding edited talks are available (via email only) by contacting Marion Stuart, marion.stuart@cancer.org.