Today we are fortunate and pleased to have our medical advisor Dr. Alan Treiman who will moderate the panel for today’s program. Each of the gentlemen on the panel will speak for just a few moments, give their background, the kind of treatment they had, and maybe a little about how they are doing now. After that we will open for questions and answers hopefully; just talking with the panel. Dr. Treiman will jump in whenever he feels it is necessary and answer any questions that might be medically related. 

Our panel members include Alan Stern, who has had surgery; Tom Cable, who had cryosurgery; Art Iverson will speak about hormone treatment, and Paul Zatz will do radiation. Without further ado we will turn to the panel.

(Edited version):

Art Iverson: Nine years ago I was diagnosed with a PSA of 34 and a Gleason of  9. Then the first five and a half years I was on intermittent hormone therapy with the usual Lupron/Casodex business, which worked quite well. At the end of five and a half years since I had not metastasized, it was decided that I was a candidate for radiation and seeds done by Hickcon Ragda up in Seattle. I gather that he is the grandfather of that procedure here in the states. So, I went through that and I got the whole nine yards on that one. So, afterwards Dr. Charles (“Snuffy”) Meyers, who is my doctor, kept me on the hormone treatment for six more months because I understand that it takes that long for all the cells to die off. And, when we finished that he then put me on maintenance, in my case, Avodart. The result has been quite good, with the ultra-sensitive PSA below 0.01 which is its detection level. And that has worked quite well. The only problem that has surfaced is that the dihydrotestosterone was high and he suppressed that by doubling up on the Avodart. However, the testosterone is low less than half of the low point. And, we are working on a new schedule for that. He had me on DHEA, vitamin D-3 and a few other things and that did not seem to do the trick. I gather that is the one that normally works. The next one is that he will be using the seven Keto DHEA along with Aramide and increase the DHEA. I’ll be starting that shortly and we’ll be running constant tests monthly to see how it goes. He showed me the chemical reaction and apparently it is a pretty complex one. And, we will wait and see what happens.

Dr. Treiman:  I think this illustrates two things. Number one, this guy is incredibly lucky. Do you gamble? You should! This isn’t a typical case. And, we have to be careful that whenever we have a panel we tend to have guys with great stories and he has a great story, a real success story. Someone who presents with a PSA of 34 and a Gleason of  9 obviously is very high risk for recurrence of the cancer within five years. The fact that he didn’t become hormonal resistant and then went on to have radiation that’s not the type of thing that we see as a standard form of treatment. Now, this happened nine years ago that all this started? Correct? So, I think that if he presented today we have other tests like a ProstaScint scan and everything. We might have said that gee if he doesn’t have any distant metastases with a PSA of 34, we would radiate him up-front with hormones for at least a year or two. So, I think we would have treated you a little differently. It begs the question whether or not you needed the five years of hormones before the radiation. But, fact of the matter is he is a success story and that is a very impressive story. With a Gleason of 9 and a PSA 34 presenting; there is some luck involved in every case. And, this is not the normal presentation for a prostate cancer that will then respond so well. So, we just have to keep that in mind. I have patients that present with much lower PSA and go on to not have as good a result. This is a spectrum. He is at one end of the spectrum and has done very well with this and I applaud the aggressive treatment. Very aggressive!

Paul Zatz: I was diagnosed in March of ’96. I was 58 years old. I had a PSA of 4.6, Gleason of 5. As I started to do my homework I realized that it did not appear to be a very aggressive cancer, all the scans were clear. I got a lot of opinions from a lot of different places from radiation oncologists and from surgeons and medical oncologists. Each wanted to do what they were expert in. I too went out to Dr. Ragda in Seattle; he had gotten a lot of publicity at that time, on the cover of Fortune Magazine or somewhere like that with the seeds and radiation. I decided that was what I would like to have. They put me on Casodex, an oral drug, for a while to shrink the prostate, during that spring.  Then in the fall of ’96 I had seeds done. I went in about 8 a.m. and by noon I was out having lunch with my family. The radiation that I had caused some scarring and blockage, and for about 10 months I was unable to urinate on my own. That is not a lot of fun. I had to wear a catheter all the time. After I moved to Sarasota, I went to one of Dr. Treiman’s partners. They decided that they would teach me how to catheterize myself, which didn’t sound like a lot of fun either. But that worked out pretty well, and I was able to get my life back. Eventually after the radiation effects subsided, I had a “TUIP” (an out-patient procedure) and I could urinate again. But not only could I urinate again; I was urinating like I was 40 years old. Since that time my PSA has gone up and down. I had the radiation bounce which no one told me about and scared me half to death. But then my PSA went up significantly into 2 to 3 range after being down below 0. I had a biopsy that indicated that my entire prostate was filled with cancer. I had a second opinion done on the biopsy pathology results, by Moffitt and also out in Seattle and the Westchester Medical Center. They figured out that there really wasn’t any cancer in my prostate. It was the radiation scarring that was there. At the same time my PSA went back down. So, I guess that was what it was. Today I am a big advocate of getting a 2^nd opinion of the biopsy. Since that time my PSA continues to go up and down, ranging from 0 all the way up to 10. The doctors aren’t too worried about it, and I’m not either. I have had the PAP test taken and it is normal, my dihydrotestosterone is very low. The only thing I take is Avodart, which works well for me, and I have little or no side effects. I am healthy. I am able to have an erection. I can urinate well. And, I am doing o.k. I am able to play racquet ball, travel, play golf, lift weights, and come here and irritate a number of you. Thank you!

Dr. Treiman: Again, not the typical case. A 4.6 PSA with Gleason 5 is pretty typical. He was 58 years old, so he would not do “watchful waiting”. If I saw these numbers in a 75 or 80 year old I would probably tell him not to do much and we would follow it pretty closely. But, in any event, he had seeds at a time when seeds were getting going. We do not see as much urinary retention any more; we are better at gauging the dose and proximity of the seeds to the urethra.  You may have had a large prostate and that is why they put you on Casodex. And, then he had what they call aTUIP which is just an incision that we make in the prostate. Beware! If you have had radiation therapy and you have urinary retention, do not have a trans-urethral resection of the prostate (TURP), because you run a high risk of urinary incontinence. The sphincter and the bladder neck are affected by the radiation, so if you go in and remove a lot of that tissue you remove what is left of your continence mechanism. That’s not good. The only other unusual thing with Paul’s case, is his PSA bounce. We don’t understand it. About 18 months out all of a sudden someone’s PSA will go up after radiation, either seeds or external, and we don’t understand that. The fact that it stills bounces around is a little strange as well. And, finally the biopsy of a guy who has already had prostate cancer and has had radiation is hard to read. You must tell the pathologist that this guy has had radiation and then you have to find somebody that looks at this stuff everyday because it is very hard to read after radiation. So, I think other than that…not your typical case once again but illustrated a lot of great points.

Alan Stern:  I had the TURP procedure done because I had BPH. This was 1983. My prostate was considered to be benign but I was having problems urinating. I was leaking. The tissue that came out of this roto-rooter procedure was sent to the pathologist who considered them to be benign. At that point I had no history of prostate cancer. When I turned 50, my doctor checked my PSA, and it was 3.5, up from 2.0. He sent me to Dr. Treiman. We did a 2^nd PSA three months later, and it was 6.5. The change in the velocity is a characteristic of probable disease. Dr. Treiman did a sextant biopsy; He found cancer throughout the prostate gland in one lobe and in 5 of the 6 cores. My Gleason was 6.

Dr. Treiman:  80% of Gleason scores are 6. The most common is a 3 so you add 3 plus 3 to get the total Gleason of 6. The pathologists like to call everything 3.

Alan Stern: The pathologist said I had cancer down at the apex of the gland which is the area where it has a habit of metastasizing. So Dr. Treiman suggested that I consider surgery as one of the options. Again, I did my homework, I went to the web, I talked to a lot of people and I came back and I asked him does he feel that we could remove the cancer and have it out of my body with good margins. And, he felt we could. I was just 70 years old and the procedure was done surgically. It has been 11 years now and my PSA has remained 0.0. I am very pleased. So, the surgical process worked very well. I had no problem being able to urinate once I healed. And I was able to take a course in strengthening the sphincter muscles. I had no problems in terms of sexual activity either.

Dr. Treiman:  When we do a TURP we remove the glandular part around the urethra. The part that is left behind, the peripheral zone of the prostate is what gets cancerous. So if you’ve had a TURP you should always have it checked. Also, once you’ve had a TURP, all the treatments are a little more difficult, because the TURP causes scarring and it causes some problems with the bladder neck and the sphincter. So, if we radiate you, you could be incontinent. If we operate on you, the operation is 10 times harder because of the scar tissue and the fact that a lot of the tissue isn’t there any more. So, it is harder to do the operation because of the scarring. It is harder to spare the nerves and it is harder to get the men back together again and make them continent. Now we have successful medications for men having urinary problems, so the number of TURPs being done is only about 20% compared to what was going on in the 80’s. We are seeing less and less guys who have TURPs who have cancer. But, again Alan has done well. And, even though I’m a surgeon I do probably more radiation than I do surgery. I put in seeds, I do cryo, I do everything. So, as a surgeon, probably the least treatment option that I offer now is surgery because of our age group in Sarasota.

Tom Cable:  In 2002, I was 63 years old, and I went to buy life insurance. They did all the testing on me and my PSA was 5.2, and the insurance company denied me. Normally it was 4.2. A month or two later my PSA was 5.9. Dr. Barzell did the biopsy, and found my right side empty of cancer, the left side base was 90%, the midsection was 60% and the apex was 35%. My Gleason score was 6. Dr. Barzell suggested either radical, cryo on both sides, seeds, radiation, cryo on one side, or just watch and wait. So, I did a lot of research. I went on the internet.  I read Dr. Patrick Walsh’s book, “Surviving Prostate Cancer.” I talked to a lot of people, read things from Man-to-Man, got it down to radical or the cryo on one side. So, I did decide on cryo on one side. I had it done on November 20, 2003. The only pain that I had was from that stupid catheter. That was my biggest problem – the catheter. Ten days later I played golf and went back to work two weeks after that. So, it turned out fine. Barzell said I would always have a PSA. My PSA originally after the operation at six months was 1.8 and went down to 1.4 then 1.2 and the last was 1.04. The only real problem I have is once in a while I get a weak or mild stream. What I do then is take Flomax for about two weeks and that clears it up right away. But I am very happy with the cryo.

Dr. Treiman:  Have you had a follow-up biopsy of the other since your cryo?  And, it’s been negative? That’s an important thing. The reason that you never saw anything about unilateral-cryo is because we invented it. Dr. Barzell came up with the idea of mapping the prostate. In your era we were doing six biopsies; now we do 12 biopsies maybe 18 in some cases. Statistically six core samples weren’t enough and we missed a lot of cancer. If you biopsy a prostate and the PSA keeps going up, then we do mapping of the prostate. Instead of going through the rectum we go through the skin below the scrotum just like you would for seed implant. And, we can do as many as we want, sometimes we do 50, 60, 70 biopsies of the prostate. That’s called prostate mapping. Around the time that we got interested in doing cryo we had Dr. Gary Onik come down to help us set up our program. He is a radiologist, my training, and got into cryo years ago and became an expert in it, in practice in Celebration, Florida. We brought him down and we did the first 30 cases with him sitting in the room and we taught him stuff and he taught us stuff. It was a good relationship because together we came up with the idea of the mapping and cryo. If we could do 50 or 60 biopsies of the prostate and then map it out in 3D and find out exactly where the cancer is maybe we only have to treat the cancer and not the entire prostate. We used to think that prostate cancer was a diffused disease; if you have one positive biopsy odds are that cancer is everywhere in the gland. When we started mapping the prostate we found otherwise. There are some very discrete areas of cancer and if we want to we can just treat that cancer in the right guy. You have to have a relatively low Gleason score, a low PSA and a localized area of cancer. We do a minimum of 50 or 60 of the whole prostate. Then we have a kind of a template and we fill in the blanks of all these areas and we can tell exactly where the cancer is. Then we just treat that area. Dr. Onik recently wrote a book on the procedure. You can find information on the internet on what is called the “Male Lumpectomy”; equivalent to what we do in breast cancer now. If you have a breast cancer in one quadrant of the breast we do not lope off the whole breast, we just remove the lump and then use radiation or some other modality. So what we are able to do once we map the prostate is to just freeze that side. But we have to do a lot of lifetime surveillance to be sure that the other side won’t develop cancer in the future. Another advantage of cryotherapy is that if you only freeze one side, the nerves on the other side are spared and you preserve potency. Doing cryo on both sides results in 100% im potency, so this “male lumpectomy” has an advantage. This is still quite new, and Dr. Barzell just wrote a paper on this, causing a lot of flack from a lot of the old-line urologists because it kind of goes counter to everything they were taught. But it is slowly gaining acceptance, and I think you’ll see more of this. The exciting news is that we are going to try to work on this with seeding. Rather than seed the whole prostate, why not seed the half where the cancer is, and save the patient some potential problems with urinary retention or rectal injury. So this is a whole new era of looking at the prostate like breast cancer where it might be focalized in one area and we only treat that. So again another unusual case. No one here is typical. There is no one here with a PSA of 6, had a radical prostatectomy, went home and that’s the end of it.  But, that’s good. We’ve all shared a lot of interesting points. Thank You.

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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.