Dr.Smith introduced the topic of Sexuality and Prostate Cancer suggesting that he would be believable in the subject as he is a retired ob/gyn that had a special interest in female sexuality and had a radical prostatectomy in 1998 with the attendant sexual dysfunctions.

Outlining what his talk would comprise, and by using visual slide projections, he demonstrated some ways we may have been brought up sexually and listed myths that accompanied our upbringing. In relating some of the things we should have learned, he demonstrated how alike males and females are in their reproductive and sexual organs, all starting out the same and developing homologous organs depending on our genetic makeup of either XX or XY.

He talked of the effect of the nervous system has on our sexual response, from the brain that responds to genital stimulation and sends either positive or negative messages down the spinal cord, or initiates these messages primarily and that negative messages can result in cycle of sexual dysfunction.

Dr. Smith described the female sexual response as it has been re-defined from the original Masters and Johnson work as an interdependence of central and peripheral (brain and genitalia) with central predominating and that desire is responsive rather than primary. Emotional intimacy comes first, permitting sexual stimulation that may lead to arousal that then leads to desire and that simple satisfaction must be added to the response cycle.

As far as the male’s sexual response is concerned, hypoactive desire is unusual but age and long term relationships may result in an arousal phase dysfunction. Life changes that affect our sexuality include long term relationships, children, work, and social and other interests. He described the normal sexual changes as we age for both men and women and stated that older men, particularly with prostate cancer, and women are closer in their sexual response cycle as willingness is necessary for both.

Categories of drugs that affect our sexuality include sedatives, analgesics, some hormones, antihypertensives, antidepressants, and antihistamines; adding that many medical conditions affects our sexual response and interest.

Addressing the specific effects of prostate cancer therapy on our sexual response he described a study out of the University of Michigan that, by means of a survey at 2 and 6 years post therapy, looked at quality of life outcomes after therapies of radical prostatectomy, conformal computer assisted external radiation, and brachytherapy (seed implants), designating outcomes on a scale of 1-100 and comparing them to age matched controls.

As far as sexual response was reported (an erection firm enough for intercourse) controls were 63; and at 4-8 years after therapy- radical prostatectomy was 38.5, conformal radiation 35.1 and brachytherapy was 27.9.

Factors influencing post therapy erections was a.) Function prior to therapy, b.) For those undergoing surgery nerve sparing and prostate size, c.) Retention of seminal vesicle tip, d.) For all the importance of sex as it relates to intercourse.

The point was made that we don’t know all of the factors that go into the achievement and maintenance of an erection and the efficacy of the use of pills for penile rehabilitation was questioned, as penile stimulation is necessary for them to do any good.

There was a discussion on the concept that “having sex” is not confined to only having intercourse, as a loss of intimacy can result if one clings to that concept as signals that used to indicate a wish for intercourse, might have evolved into just a wish to touch, and rejection of the touch may occur if one is still thinking before the evolution. But, if intercourse is planned there may be help needed for erection and lubrication for her. Aids for erection were described as pills, vacuum pump, “Muse” the urethral suppository of prostaglandin, penile injection with the “Caverject” pure prostaglandin or trimix, a mixture of papaverine, phentolamine and alprostadil, and penile implant. Dr. Smith made the point that if erection is achieved, intercourse will be cruel and unusual punishment if a lubricant is not provided for his presumably menopausal partner in the form of “over the counter” products like “Astroglide” or “K-Y Warming Liquid.”

He ended his presentation with the plea that couples not lose their intimacy if intercourse is not possible or wanted, to remember that sex can take many forms, and that willingness is necessary for both, as what was available in our youth is no longer present.

The speaker for the April 23, 2007 meeting was Jan Manarite. She is Florida Educational Facilitator for the Prostate Cancer Research Institute (PCRI). Her topic was entitled, “Tools for Patient Empowerment.”

The analogy I will present today comes from my husband. Although he is not present here today, he is alive, and a prostate cancer survivor. In March of 2000 he was diagnosed with prostate cancer. His PSA was 7096! Today, with treatment, his PSA is 2.5. This came about after intensive research and thoughtful treatment choices on our part. I say, our part, in that he and I participated together in this quest. He started out having severe back pain, sleeping on a recliner for several months. An MRI eventually revealed extensive bone metastasis particularly in his thoracic spine region. The pathology report on the surgically removed spinal tumor demonstrated that this was, in fact, metastatic prostate cancer. This becomes a different kind of story leading to his diagnosis, because he never had a prostate biopsy.

My husband did have symptoms, but I want to make a point here about symptoms. Symptoms have nothing to do with early detection. Screening procedures should be done in the total absence of symptoms. That is the basic concept of screening. So, where does the prudent person start? There is so much information out there. I’m guessing that a lot of you have felt these initial emotions especially in the beginning. We had to move past those feelings. Anger, tears, fear, frustration all those things are part of cancer. You want to embrace those together and work through them. But, once you move past them you’re probably to a place where you can really embrace empowerment because you can’t go to a doctor’s visit angry. You can, but it’s not going to work. One must get beyond their anger and frustration and become objective. Which is one of the things that PCRI does, I think, is to help people get to objective information in an emotional setting. It is a real challenge. It’s like mixing oil and water. That’s my analogy. However, we can do it.

Here’s some thing that I have learned. I just want to share these with you. My anger is disabling, not empowering. So is my frustration. My goal is to try to get past that. So, how can I get there? I learned to give myself permission to put research aside because you will get overwhelmed. You will get lost on the Internet. You will get lost in a book. Just put it down and come back to it. You may feel a sense of urgency about everything, but you may find that you have to give up that sense of urgency just for a while to get where you want to get.

Obviously in our case that was the situation. It was the priority. That means you have to let some other things go. But, that’s OK, because when you look at the big picture, no matter how you look at it, my husband was the single most important thing. That was a challenge. It was a new way of thinking. That was one of my lessons.

What happens is people in the family rise up, and they want to help. Most of those people are only doing that because they love you. Everything that we do is based on love. People who fight for you, who advocate for you, are doing it because you are so important to them. Sometimes that gets a little mixed up, but that’s the truth.

Other new relationships have to do with the physicians involved. It is a relationship. When you go to a physician’s appointment and you leave feeling frustrated; that doesn’t mean that you need to change physicians. It means that you need to work on that, because it is a relationship. If over a period of time that doesn’t work for you, for whatever reason, maybe that’s the time to consider changing. It is, by the way, ok to change physicians. But it is something that you need to give some thought to.

The only thing I finally realized is that in this fight for cancer, perfection isn’t the goal. But beating the odds is. Defining a prognosis; that’s the goal. Boy, that’s precious, and nobody can take that away from you. The following Toolsets will prove helpful in reaching your goal.

This will probably be easiest to do while speaking with your physician at the office. It often proves difficult when calling your doctor’s office and dealing with a busy receptionist. She has probably been instructed to be cautious in what she says, and does because of the privacy issues that we deal with now. Also, it will be easier for the patient to obtain his own records as opposed to the wife or other family member—not impossible, but more difficult.

Here is a list of some of your primary records to ask for, in order of probable importance:

1) Pathology report from surgery (if you had surgical removal of prostate).

2) Pathology report from all biopsies, especially the biopsy which diagnosed you initially.

3) Pathology report from TURP (transurethral resection of prostate) if you had one.

4) Ultrasound report from biopsies (written report).

5) History of PSA blood tests, before and after treatment.

6) Written reports from any films, including: A Bone scan, MRI’s, X-rays, ProstaScints, Bone Mineral density tests (QCT or DEXA), CT scans, Ultrasounds.

7) Other blood markers run for prostate cancer, such as free % PSA, PAP, etc.

8) Other blood and urine tests.

9) Records of treatments given, including: written surgical report, radiation dose report.

10) Compile a list of all current medications, each medication should have 3 pieces of information: name of med. (every drug has two names; trade name and generic name), dosage taken, how many times per day.

11) Compile a list of all supplements/vitamins: name, dosage, how many times per day.

Place this information in chronologic order for ease of reference. Highlight dates and important words.

Have as many, or as few books as you like. Remember, a lot of the information you need can be found online. Here is my personal book list:

1) PDR (Physician’s Desk Reference). This book was originally produced for physicians, but is now available in simpler language with actual color photos of pills for identification. It is important to understand the drugs you are taking, and their side effects. DO NOT assume that someone else has thoroughly looked over your drug list with the same interest that you would.

2) A Primer on Prostate Cancer; The Empowered Patient’s Guide (by Stephen Strum, MD and Donna Pogliano).

3) Medical encyclopedia or medical reference book of some type.

 

If you do not have a computer, you can use the computers at your local library for free. If you do not have e-mail, or know how to use the internet, ask your local library about upcoming computer classes. Most of them are free. Your instructor can help you obtain an e-mail address from one of the websites that offers free e-mail.

1) Egroups (lists, discussion also called internet mail lists, mailing lists, discussion groups, etc.) These are FREE lists that you subscribe to with your e-mail address. These groups tend to be made up of patients and family members who are educated and empowered about their disease. Be careful of actual medical advice. Remember that disease is emotional, and every man’s cancer has its own individual characteristics. Know what yours are.

2) Email newsletters- “aware” by the National Prostate Cancer Coalition. Go to ^{www.pcacoalition.org. Click on “Aware” on top right. Another reliable website is FDA prescription drug info. Go to www.fda.gov. Click on yellow box on bottom left- “Subscribe to FDA’s free e-mail newsletters.” Click on FDA Newswire or MedWatch, or one of the other lists to receive current and updated info on prescription drugs.}

3) Websites-General prostate cancer info. Prostate Cancer Research Institute ^{www.pcri.org, UsTOO! www.ustoo.org, and Prostate Pointers www.prostatepointers.org.}

More scientific info on prostate cancer: PubMed ^{www.ncbi.nlm.nih.gov/PubMed. Learn to look for the actual abstracts (summaries) from studies relating to your disease. Full text articles can be obtained for a modest fee and sometimes free. Additionally, try talking with the reference librarian at your local public library. Sometimes they have access to special sources as a library. Go to your local hospital’s medical library on site, but call ahead to inquire about their hours. Email the author of the study if the email address is in the citation of the article. They usually email in a .PDF attachment. You will need Adobe Acrobat in your computer to receive it.}

Learn to read abstracts- ASCO’s website is ^{www.plwc.org, Look for “Feature Article” entitled PLWC Feature: How to Read a Medical Abstract. To access a Medical Dictionary; www.dictionary.com, or ASCO’s website (see above).}

Here are the two that I found to be the most valuable:

1) PCRInsights- This is PCRI’s quarterly newsletter. It is free. You can subscribe by calling me, Jan Manarite at 230-395-0995, or emailing me at ^{JManarite@pcri.org. Articles are mostly written by expert physicians, and cover a wide variety of topics.}

2) Prostate Forum- This is Dr. Charles “Snuffy” Myers’ newsletter. The topics vary but are an excellent tool, as they are Dr. Myers’ writings based on the review of the scientific literature, put into plain English. Subscribe by calling 800-305-2432, or log on ^{www.prostateforum.com.}

These opportunities offer not only excellent information, but the chance to meet and talk with others. Here are a few ideas:

1) The National Conference on Prostate Cancer sponsored by PCRI, FCRE and Us TOO! Visit ^{www.pcri,org.}

2) Check out the Events Page on PCRI’s website.

3) Man to Man Support Groups (American Cancer Society). Check local chapters.

 

PCRI has a wide variety of recordings available on our website at ^{www.pcri.org.}

Remember to move past your emotions and learn to research information relating to your cancer. Just start somewhere and give yourself some time. It will be a “learning curve” but you are going to get more accurate information about the science of your questions. However, one must always be aware that not all information gleaned from some of the above noted resources would necessarily be totally reliable. Bad information abounds; therefore, it is always prudent to check with your doctor. Thank you for your kind attention.

__________________________________________________

Dennis Welch: I’ve lived here in Sarasota for six years. I am originally from Chicago. In 1997, at sixty-six years of age, they diagnosed me with prostate cancer. I had a PSA of 7.5 and a Gleason Score of 4. I took my wife in with me. I figured that she made so many decisions for me I’ll let her help me make this one. To make a long story short we decided to get surgery. Ten days later on a Thursday I went in and had the surgery. I had my prostate completely removed. Since then my PSA has been zero. I have no problems. I take no pills, no hormones, nothing. I go to see my primary care doctor and urologist four times a year, and, they check me out.

On the surgery, the only problem that I had was the catheter. Boy, that was a rough grind! Since then I’ve had no problems whatsoever. Everything works; nothing hurts. The only medicine that I do take is for blood pressure and cholesterol. All I can tell you now is I could cover a lot more things but I find out that sometimes when people ask questions you learn a lot more from that. So, I am going to be around here for a while. And afterwards you can talk to me about it. I’ll be happy to answer any questions. I hope to talk to you later.

Scott Styles: Good afternoon. I’m supposed to talk about hormonal therapy. I have to start by telling you that I was originally diagnosed with prostate cancer in the fall of 1996. I had a PSA of 5.5 and a Gleason of 6. I evaluated a lot of options and decided on brachytherapy (seeds). I had it done at Moffitt Cancer Center in Tampa. I began with a treatment of Lupron and Eulexine six months before I had the seeds. I had the seeds in March of ’97 and it went beautifully. I was hospitalized overnight and everything went smoothly. I had no problems. My PSA dropped to less than 1 and stayed there for several years.

But then, in 2003, I noticed that it was beginning to rise. I get a PSA test every quarter. I watched for a quarter or two and it was going up. So, I went back to Moffitt, and had another series of biopsies (twelve this time). I found that at least 2 of the 12 had recurring cancer.

At that point I had a new decision to make, because there are not a lot of ways you can radiate if you have already had seeds. So, I spent almost a year, because my PSA was going up rather slowly, trying to sort out what the options were. Finally they were narrowed to reseeding, cryosurgery, or hormonal therapy. I found out that reseeding might result in my becoming incontinent, so I moved on.

After carefully investigating the three options, and at the suggestion of Dr. Gary Onik, I decided on hormonal therapy rather than cryotherapy. His comment was, why don’t you try hormonal therapy, because if it doesn’t work, or you find it too debilitating, we can still come back and do the cryotherapy. I said OK and that is how I left it. My PSA was moving slowly upward and it was up to about 5.5 again when I began the hormonal therapy, which consisted of Casodex and Avodart, but no Lupron. Many doctors now do believe that Lupron is a desirable third part to this process. But, the doctor and I decided against that. When I had taken Lupron before my seeds I had very severe reactions. Dr. Friedland, my radiation oncologist, said “Let’s not go through that, let’s see if we can do it with just the Casodex and the Avodart. So, that is how I proceeded. For a year my PSA came right down to 0.1 and varied only slightly. It stayed in that range, so I didn’t worry. And then after a year he said, “Let’s go into the intermittent phase for six months,” which I did. My PSA moved up rather rapidly, so after six months I was up to 0.6, and went back on the hormonal therapy. I took that for another year, and again, the PSA went right down and stayed at 0.1. I came off hormones just about three weeks ago and I am now in a period where I am not completely unmediated. I’m taking Avodart because it seems that very often Avodart or Proscar will help you extend the period when you actually are off the hormonal therapy. So, I’m hoping that that is going to work for me. But, we will find out over time.

So far as the treatment is concerned, I had minor discomfort with both of the series of hormones. I did notice that I had a loss of energy. Other than that I had a pretty good quality of life, which is what I wanted. I had minor incontinence. It was more urgency than it was actual leakage. I found that I couldn’t wait to long. When the call came I had to hustle. But, other than that life was very good. Another side-effect, which is not uncommon, is breast sensitivity and enlargement. I noticed that with both of the series of hormonal therapy. It wasn’t to the point that it was debilitating, but sensitive. I could have chosen radiation to keep that sensitivity down, but I chose not too because I’d had a lot of radiation earlier in my life. I found out later that the breasts will not go down when you get to the waiting stage on this intermittent therapy. Apparently the enlargement will stay with you. So, that’s not very good news. I wish I had known that earlier; I might have changed my opinion on not using radiation. However, the quality of life for this whole two and one half years has been excellent. I’ve enjoyed life.

I’m waiting for July to see what the PSA test shows, whether it is going to stay down there at 0.1 or whether it’s going to begin to creep up. Other than that, I’m looking forward to enjoying continued pleasant living, generally in very good health.

Dr. Klotz who spoke here about three months ago indicated, that in his experience, you can wait longer than just getting up to 0.5, 0.6 or 0.7 PSA. Also, he was not as concerned about the rapid velocity of the PSA change. So, I think this time, I am going to wait a little longer before I leap back into the full hormonal therapy.

Robert Eaton: I am seventy-four years old. My subject is Cryosurgery which freezes cancer cells to death. In about a two and one half hour operation, 12 rods are put into your perineum, which then are brought down to a very intensive sub-zero temperature. The freezing temperature is achieved and then thawed. When it is thawed, they refreeze a second time, and then thawed. Back in January 2002 I had a routine physical which showed that my PSA was 4.0, and it had climbed over the years from 1, 2, 3, and 4. My primary care physician said it would be a good idea to see a urologist and have him check it out. The urologist suggested that I have a biopsy which showed that there was cancer on both sides of my prostate. I had a Gleason of 7. My wife and I, together with the doctors, discussed various possibilities; we agreed that surgery was the best route to take. It was scheduled for March 19, 2002. About five or six days before that date I came to the hospital for routine examination before the surgery. They found some kind of problem with the electro-cardiogram. They said that they would like to do an angiogram to check if there was any coronary artery blockage. They detected blockage, and I had a second angiogram a couple of days later in Tampa, using a different technique. That confirmed that there was blockage and the two cardiologists involved said there is no way that we will approve your undergoing prostatectomy (removal of the prostate) until you have had a by-pass operation. I asked if they could utilize stents, however they said not with the location of this particular blockage. It has to be surgery. So, instead on March 19, the exact day, the exact hospital, the exact operating room, where I was suppose to have prostate surgery, instead I had a double by-pass. I was depressed to say the least. The surgery went well. There were no problems. But, even when there are no problems it takes quite a while to recover by-pass surgery. You are very tired and physically really beat up. I said to the urologist, the cancer is spreading. Isn’t there a danger? He said “prostate cancer moves very, very slowly; I don’t think there is a danger, but, to make sure, you’ll take some hormones”. I took Zoladex, which is an injection you get in the stomach region and Casodex which is a pill you take orally. I took the hormones for six months. They brought the weight of the prostate down by 50%. It became a lot smaller. The hormones basically worked very well for me. The only thing that I did not like with the hormones was the hot flashes that you get on fairly frequent occasions during the day. But, as far as getting the PSA down; it went down and worked very well. So my heart operation was in March and we go to about September, and the prostate discussion came up again. What do we do about the prostate now? We had all those options still available. Well, having just had major surgery I certainly wasn’t keen to have another major surgery. So, we said that really we think the operation is not on, and we started talking about cryo. The first thing the urologist, Dr. Barzell, said, “Impotence is 100%.” In other words, erectile dysfunction occurs in almost every case. Other than that, it is a very positive, very good procedure. To make a long story short; we decided to go the route of cryo instead of prostate surgery. The procedure itself took place in November, roughly eight or nine months after the heart surgery. The procedure took two and one half hours. It was as I described before, carried out by Dr. Barzell, and Dr. Gary Onik, one of the pioneers in cryosurgery. I woke up and stayed in the hospital one day, then went home. I had approximately two weeks of incontinence. No problem at all right from the very beginning. I was very satisfied with the cryo procedure. Unfortunately, Dr. Barzell was correct regarding the impotence. There’s no erectile function left. But, other than that, as far as incontinence is concerned; no problem at all after the first ten to twelve days, no leakage, no nothing, all perfectly normal. I am a fan of cryo surgery. I think it is to be recommended. Obviously, if you are young, in your forties or fifties, or maybe even sixties, the fact that you have no sexual function is a bit disturbing to say the least. That, I think, is the major factor one has to consider if you want cryosurgery. Beyond that, I have no complaints what so ever. I think the procedure was good. My PSA was less than 0.1, and has stayed at less than 0.1 the entire five years since I’ve had the procedure. The cancer has not returned. I am very optimistic. The comfort factor was absolutely minimal. I was amazed after the operation; how little discomfort there was and how fast everything healed and went back to normal.

Murrel Winner: I was diagnosed with prostate cancer at the age of seventy-six. I am now eighty-two. I had a 6.5 PSA. That was in Louisville, Kentucky in 2001. I came to Florida and met a doctor here. He gave me hormone shots in my stomach. It gave me hot flashes, depression, no sleep. Also my breasts swelled a lot. This process knocked my PSA down to zero. After a couple of weeks I went back to the doctor and he recommended I have seeds and radiation. I asked if this was a guarantee to rid me of prostate cancer. He said “no”. So, you know what I told him? I said “no” also. I had a gentleman work for me for forty years that had prostate cancer. He had radiation. The rectum and the prostate are so close together, and as a result of the radiation, he was on a diaper for the rest of his life. He said “Murrel, let them do anything, but don’t let them use radiation on you”. So I listened to him, and for six years I’ve been very happy.

I go to the doctor every six months to be checked. My PSA is now 10.7. While I was doing this I met a Chemist and he was telling me what things he has done. So, I said if you could do it, I can do it. I take vitamins everyday. The most important thing is your diet. No fried food, no ice cream, no butter, no cheese, no salad dressing, no eggs, no dark meat, no red meat. Leave your whisky and your beer alone and get some sleep. For breakfast I have soy powder and cranberry juice. For lunch I drink green tea and fruit. For dinner I have red wine. I take a bunch of vitamins everyday. I take about six of them a day. I have been very pleased with my results. I don’t think the prostate cancer is going to kill me. Something else is going to kill me first. I am going to wait to worry. Other than that I am in good shape for the shape I’m in. Thank you. Does anybody have any questions? Please ask me later. I’ll tell you the best of my ability what I have done and how happy I am.

Jack Davis: I must be the kid on the block. I was diagnosed at sixty-three with prostate cancer, PSA of about 3.8, Gleason score 7 (stage T1B). One of the most important facts was that my PSA doubling time was just short of four years. I am an advocate of radiation. I had both the IMRT (Intensity Modulated Radiation Therapy) at Twenty-first Century Oncology here in Sarasota, as well as 100 seeds implanted by Dr. Treiman. So, I had sort of the double approach. Side effects were minimal, tiredness if anything else. I was advised by a friend of mine to use it as an excuse to take a nap. I took him up on that, and after several months, the tiredness tended to go away, and I got my energy back.

My comments are going to be focused, primarily, on those of you who have yet to choose a treatment option. One of the most important things that I can tell you is, be responsible for your treatment decision. Take ownership; get informed, you need to do this. I can tell you some horror stories of a boss of mine who had a urologist who told him “you have prostate cancer and you need to do this or that”. And he said OK. I tried to share with my boss that you need to learn more about your other options. He said “nope, my urologist said you need to do this, I’m not going to think about it.” I got a note, just today, from his wife. He died of prostate cancer.

I could go on with other stories, but the bottom line is, get second opinions. I was fortunate to have a urologist, Dr. Treiman, who advocated that I see a radiation oncologist for a second opinion. My cousin, who was just diagnosed; his urologist suggested that he get a second opinion from another urologist. I didn’t think that was the right thing to do. I advised him to go look further …and he did. And, he has been talking to M.D. Anderson as well as Johns Hopkins. Do get second opinions on your biopsy slides as well.

Third point; know that there are thousands of men out here who have this disease. And, like Man To Man there are discussion groups on the Internet and centers of excellence all around the country that have incredible web sites with lots of information written for the layman. You need to tap that. You need to get on the Internet. You need to talk to people. You need to get involved with groups like this because we know a lot that can help you get through this very difficult decision. And, that is probably the most difficult part of it all is making your decision.

Fourth: regarding sexuality… in my opinion, things are going to change. They are either going to change physically or they are going to change psychologically or probably a little of both. All of this is exacerbated by the fact we are getting older and three or five years out from the treatment option, you don’t know if your change in libido or sexual proclivities is the result of your treatment of your prostate cancer or you are getting older. So it is really hard to sort that out. No pun intended.

I feel that each of us who have gotten a lot of help from support groups and individuals, have an obligation to go back and do things like appear on panels, get involved on the Internet, share with others the knowledge and mistakes that you have made with others. Lastly, I can’t emphasize enough the importance of PSA doubling time in your diagnosis. I have learned its one way to assess the aggressiveness of your particular cancer. Many of my physicians didn’t even look at that. With that I will end my comments.

Dr. Treiman: Again thank you to this fabulous panel. Just one disclaimer; whenever you have patients appear on a panel, they usually are either the most satisfied, or the most disgruntled. These stories are not what I generally hear. Each one of these fellows has had an interesting road. I diagnose, unfortunately, 5 to 10 prostate cancers a week. So, I’ve heard it all in the last twenty years. I’m always amazed at the variation, and I still learn every day from my patients. That is what I like about what I do. This is why I help-start this group because you can’t keep up with every little aspect. You need your worker bees out there sending you articles and keeping you up to date. We do a pretty good job because my partners and I have done a lot of research in this and we are always connected with other doctors. We all talk to each other. What we do is we have little round tables. We have something called a Tumor Board. I don’t know if you are aware of that. Every week we get together in this hospital and we talk. All the doctors are invited, the oncologists, radiation oncologists, and urologists. Not just for prostate cancers but for every cancer. For prostate cancer we present cases and we sit around and say “What should we do?” We poll each other. We’ll ask each radiation oncologist, Dr. Dattoli, Dr. Silverman or any of those that happen to show up. We test each other on what to do. That’s how we keep up to date; and it’s great. That goes on at every hospital in the country, because that’s a requirement. We actually have a certified cancer center here. To be able to pass muster every three years we have to show that we do these things. So the way we keep up is by constantly testing each other and presenting cases. It is anonymous; we don’t mention names of patients at the time. But, when we make a diagnosis of cancer; before we go back to the patient, we get together for a long chat sometimes two or three long chats. And, sometimes I have actually discussed our cases even with my partners or some of the radiation oncologists that I run into or call. That is how we do it. So, it is not a big black box. We have as many questions as physicians, as you do. Because, there is no right answer; prostrate cancer a complex disease. I’ve been a doctor now for a long time, 27 years. While there have been some amazing advances in prostate cancer, everything that was mentioned by this panel today was there when I was in medical school in 1976. So, think about that, thirty years. In my perspective not a lot has changed, other than we now have PSA, which has helped us shift the curve more to a less advanced form of prostate cancer. Did you notice this panel of men, when they were diagnosed, had almost a normal PSA, which is a little unusual. But, we’ve become more cognizant of PSA rise and the doubling time. That is important. There are other things to consider, the person’s age, and his overall health. If someone has heart disease, it might eliminate one or two options, but we have two or three other good ones. If your PSA is going up a point every six or twelve months, that’s not a good sign. If, however, it is doubling every four years, that is a different story.

Audience Question: What do you think happened? Why did Scott’s cancer come back?

Doctor’s Response: You’ve had seeds alone, correct? And, what was your Gleason score?

Panelist Response: Yes, seeds alone. Gleason was 6. I also had treatment with Lupron and Eulexine six months before.

Dr. Treiman’s Response: We have a different protocol now. That was in 1996. We weren’t giving as high a dose. We were concerned about radiation damage to the rectum. So, what has changed is we are more aggressive; we often combine hormones, external radiation, seeds, and give a higher dose. We have better external radiation. It is more focused. So, we have made some advances and I suspect that while he had the state of the art at the time, it wasn’t enough to kill the cancer cells.

Panelist’s Response: To answer directly to your question though; I did a fair amount of research before I decided on seeds. I had great confidence in the doctors who were doing the job at Moffitt at the time. They were using a three man team, a urologist, a radiation oncologist, and a radiation physicist, who pulled the data together before they gave me the seeds. I figured that they did a pretty good job. It was just that statistically, you are never sure you have it all. It is nice to believe you have. But, you’re never positive until you live a few years and see what happens.

Question: After a radical prostatectomy, what should the PSA be, and what happens when it goes up?

Dr. Treiman’s Response: It should be as close to zero as possible. The problem is that PSA is not always that accurate of a test. We now have the ultra-sensitive PSA test, which to my eye may be over-kill. Assume the patient had a .05 and went up to 0.1. So, you do the math. It has doubled. Depending on the doubling time involved, you might worry about that. The problem is that these tests are done by human beings, with laboratory reagents and machines that need calibrations. And, at those low levels, it’s very hard to make a diagnosis over such two points. So, what we do is look at it over the course of the next couple of years. If it goes from .1 to .3, and from .3 to .6, that’s a real deal. What will happen sometimes, it will bounce around between .1 and .05. That’s nothing to worry about. The problem is at what point do you worry? You worry when it is a straight line, three or four in a course of a year and a half to two years. Then, at what point do you intervene? For someone who has had a radical prostatectomy, who is at a younger age, any three rises in a row constitutes a local recurrence. Right away we do external radiation. We don’t fool around with that. We formerly waited until it was up to 2.0, or something like that. But, we found that was too late. The sooner you can hop on that the better. I have actually treated people who have gotten to .2 or .3 because they went from 0 to .1 to .15, to .2, and at that point, that is pretty good data that something is happening there.

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