Posts Tagged ‘radiation therapy’

Treatment Options for Men With Prostate Cancer-Side Effects You Need to Know

January 22, 2017

Prostate Cancer is the most common cancer in middle aged and older men.  It is the second most common cause following lung cancer of death from cancer in men.

This article will discuss the most common treatment options for prostate cancer and what are the side effects of these treatments.

For younger men with localized disease, surgical removal of the prostate gland either with an open 6-8-inch incision or through a robotic prostatectomy-5 small pencil-sized holes in the lower abdomen that removes the entire prostate gland.

Temporary or even permanent erectile dysfunction (impotence) occurs in many of the men who undergo surgery.  Urinary incontinence, inability to control the flow of urine, occurs in 3-30% of men who have their prostate gland surgically removed.

For older men or for men who have prostate cancer beyond the prostate gland, radiation therapy is treatment option.   The side effects include temporary fatigue, diarrhea or other bowel problems, urgency of urination, and impotence (ED).

For men with spread of prostate cancer beyond the prostate into the bones or lymph nodes, then hormonal therapy is often recommended.  Hormone therapy is used in men with advanced, high-grade prostate cancer. Hormone therapy is also used in men who cancer has recurred after being treated with radiation therapy or surgery.  This is usually determined with an elevation of the PSA level.  Prostate cancer is very sensitive to testosterone, the male hormone produced in the testicles, and removal of testosterone reduces the cancer and helps control the disease but does not cure the problem.

The side effects of hormonal therapy include reduced libido, hot flashes, softening of bones or osteoporosis which leads to bone fractures, impotence, loss of muscle mass, fatigue, weight gain, and increased risk of heart disease and diabetes.

Chemotherapy is indicated for men who do not respond to removing the testosterone produced by the testicles.  Chemotherapy leads to hair loss, nausea\vomiting, diarrhea, fatigue, muscle pain, and weight loss.

Proton therapy is a similar to external radiation that targets difficult to reach tumors and is designed to allow higher doses of radiation to be delivered to the prostate with fewer side effects.

Bottom Line:  Over the past few years there have been numerous options available for the management of localized prostate cancer and even prostate cancer that has spread beyond the prostate gland.  New Orleans has several doctors who are national and even global experts in managing prostate cancer.  For more information, contact your doctor.

Testosterone and the Prostate Gland-It’s Not Gasoline On a Fire

November 3, 2014

For the past two years I have made the decision of treating prostate cancer patients who are documented to be hypogonadal with testosterone replacement therapy. Many of my colleagues have asked me about this decision and I would like to provide you with the evidence that this treatment of hypogonadal men who have been treated for localized prostate cancer with either radical prostatectomy or radiation therapy is safe.

In the late 1980s Dr. Abraham Morgentaler, a urologist in Boston, Massachusetts, began researching the relationship between testosterone and prostate cancer.  Since the early 1940s testosterone had been believed to be a key contributor to the development of prostate cancer, and once cancer was established, testosterone was believed to be its fuel.  As a result, generations of medical students around the world were taught that providing additional testosterone to a man with prostate cancer was “like pouring gasoline on a fire.” On the flip side, it was similarly believed that low levels of testosterone protected a man from ever having prostate cancer.

As one of the first physicians in the modern era to offer testosterone therapy to otherwise healthy men with sexual problems, Dr. Morgentaler was concerned that this treatment, while effective, might precipitate rapid growth of undetected, “occult” prostate cancers in his patients.  In order to avoid causing more harm than good, Dr. Morgentaler took the bold step of performing prostate biopsies in these men to exclude the possibility that these men harbored an undetected prostate cancer, even though they had none of the standard indications for a biopsy, such as elevated PSA or a nodule.  Although it had been assumed these men were at extremely low risk for prostate cancer because of their low testosterone levels, Dr. Morgentaler and his colleagues found exactly the opposite. One in seven of these “normal” men that underwent biopsy was found to have cancer, a rate similar to that seen in men known to be at increased risk.

Dr. Morgentaler presented his findings at the annual meeting of the American Urological Association in 1995.  At the end of the presentation an influential chairman of a major urology department came to the microphone and loudly described this work as “garbage.” “Everyone knows high testosterone causes prostate cancer and low testosterone is protective,” he proclaimed in a booming voice.  The research was published the following year in the prestigious Journal of the American Medical Association.

As the testosterone and prostate cancer link became less persuasive, Dr. Morgentaler began to offer testosterone to men with pre-cancerous abnormalities on prostate biopsy, and reported no increased rate of subsequent cancer. Yet at his own hospital, the Beth Israel Deaconess Medical Center, a senior endocrinologist complained to the administration that this research was “dangerous”.

However, Dr. Morgentaler prevailed and went on to publish clinical research on the safety of testosterone in men with actual prostate cancer, some treated with radiation or surgery, and even in selected men with untreated prostate cancer.

Dr. Morgentaler’s results were difficult to accept initially because a longstanding treatment for advanced prostate cancer has been androgen deprivation, a surgical or medical treatment designed to permanently reduce testosterone levels as much as possible. Numerous studies in these men had shown improvement in prostate cancer with this treatment, so it seemed logical that raising testosterone would cause prostate cancer progression.

Dr. Morgentaler’s elegant solution to this apparent paradox was the saturation model, based on studies in humans, animals, and in prostate cancer cell lines in the laboratory. It turned out that prostate tissue does indeed require testosterone for optimal growth, but that it can only use a limited amount of testosterone (or its metabolite, dihydrotestosterone) before it reaches a maximum. In biological terms, this is called saturation.  Once saturation is achieved, additional testosterone has little or no capability to stimulate further growth. And saturation occurs at very low levels of testosterone, approximately 20ng\dl. This explained why testosterone treatments did not appear to harm men with existing or treated prostate cancer, namely because the cancers already had seen all the testosterone they could use.

The Evidence

A number of physicians have treated patients with testosterone despite the fact that they’d been treated for prostate cancer in the past. The first to publish their experience with doing this were Drs. Joel Kaufman and James Graydon, whose article appeared in the Journal of Urology in 2004.

In this article, Drs. Kaufman and Graydon described their experience in treating seven men with T therapy some time after these men had undergone radical prostatectomy as treatment for prostate cancer, with the longest follow-up being 12 years. None of the men had developed a recurrence of his cancer. Soon afterward, there was another paper by a group from Case Western Reserve University School of Medicine describing a similar experience in 10 men with an average follow-up of approximately 19 months. Then another group from Baylor College of Medicine reported the same results in 21 men.

In all these reports, not a single man out of the 38 treated with testosterone developed a cancer recurrence. It is important to emphasize that all these reports included only men who were considered good candidates because they were at low risk of recurrence anyway. And in some cases, the duration of time the men received T therapy was relatively short. But it was reassuring that none of the 38 men who had suffered from prostate cancer in the past and who were treated for years with testosterone had developed a recurrence of prostate cancer.

This reassuring experience was bolstered by the published experience of Dr. Michael Sarosdy, who reported the results of T therapy in a group of 31 men who had received prostate cancer treatment in the form of radioactive seeds, called brachytherapy. This less-invasive form of treatment does not remove the prostate, so theoretically there is the possibility that a spot of residual cancer might still be present. With an average of five years of follow-up in these men, none of the 31 men had evidence of cancer recurrence.

My Approach

Men who have low-grade prostate cancer, i.e., Gleason score of <6, and low stage disease, T1 or T2, and have a nadir of their PSA following curative treatment with either surgery or radiation for 9-12 months, and have symptoms of hypogonadism and documented low testosterone levels, are candidates for hormone replacement therapy. I provide them with educational materials similar to what is in this newsletter and request that they return every month to monitor their PSA levels. Any increase in PSA levels for two successive months results in cessation of their hormone replacement therapy. Of the several dozen patients that meet this criteria and have received testosterone replacement therapy, none have had a rise in their PSA or evidence of recurrence of their prostate cancer.

Bottom Line: Today, most urologists throughout the world, myself included, are comfortable using testosterone in men without the fear of causing prostate cancer, and in the US a majority will now offer testosterone treatment to some men previously treated for prostate cancer.  This revolutionary change in medical beliefs and practice resulted directly from the work of Dr. Morgentaler, who became a David against Goliath and was relentless in his pursuit of scientific truth and making it possible for some men who have prostate cancer with documented hypogoandism to receive hormone replacement therapy.

PSA Elevation After Treatment For Prostate Cancer

July 24, 2014

Prostate cancer represents the second most common cancer in men following lung cancer. Prostate cancer will be diagnosed in nearly 250,000 men annually and causes nearly 40,000 deaths each year. If you already have had prostate cancer treatment, changes in PSA levels can tell whether treatment is working.

After surgical removal of your prostate, your PSA levels should be undetectable. After radiation therapy, the PSA levels should drop and remain at low levels.
Signs that your cancer has returned may include one of these:
Three consecutive PSA rises above the lowest level over time
Confirmed rise of more than 2 ng/mL from your lowest level

The key is monitoring your PSA levels over time. A rapid rise suggests rapid cancer growth and the need for treatment. A very slow rise of the PSA can often be watched.
But PSA levels can also be somewhat confusing. For example, they can go up and down a bit for no reason. The PSA test is not precise, and minor changes from test to test are to be expected.
Low rises of PSA levels can’t predict your longevity or symptoms when you have cancer. But high or rapidly rising PSA levels can suggest future problems.
That’s why doctors take other factors into account when evaluating your situation. Talk with your doctor to get a better idea of what to expect, so the numbers don’t add to your anxiety.

Advanced Prostate Cancer and PSA Levels Over Time
If you have advanced prostate cancer that has spread outside the prostate, your doctor will be looking less at your actual PSA levels than at whether and how quickly PSA levels change.
Doctors use changes in PSA levels over time (called PSA velocity) to tell how extensive and aggressive your cancer is.

Your doctor won’t just look at one PSA reading at a time. He or she will confirm it with multiple tests over many months, especially after any radiation therapy. That’s because you can have a temporary bump in PSA levels for about one to two years after radiation treatment.
To determine how aggressive your cancer is and whether further treatment makes sense, your doctor may also consider your:
PSA levels before cancer
Grade of cancer or the Gleason score. The higher the Gleason score, the more aggressive the cancer.
Overall health and life expectancy
PSA Levels and Treatment for Advanced Prostate Cancer
Your symptoms and how long it takes for your PSA levels to double (PSA doubling time) affect decisions about how soon to try treatment such as hormone therapy.
Your doctor will look at how quickly or slowly PSA rises before deciding on which treatment to suggest. You may need continued monitoring before moving to a new treatment. Your doctor may suggest waiting for a while to delay the appearance of treatment-related side effects. Discuss with your doctor how to weigh these considerations.

PSA levels may also be useful in checking if your treatment for advanced prostate cancer is working after you have had:
Hormone therapy
Chemotherapy
Vaccine therapy
Treatment should lower PSA levels, keep them from rising, or slow the rise, at least for a while.
Doctors monitor PSA regularly based on the type of treatment you had first. For example, after hormone therapy, PSA should drop to a lower level quickly, i.e., within weeks. It may fall further over time as you continue hormone therapy.

Combined with symptoms and other tests, PSA tests can also show if it’s time to try another type of treatment.

Bottom Line: PSA is an imprecise test for diagnosing and monitoring prostate cancer. If the PSA rises quickly after treatment, whether it is surgery, radiation, or hormone treatment, this is of concern and you may need to have additional treatment. Speak to your doctor if you have any questions.

PSA Rise After Treatment for prostate cancer

June 23, 2012

Nearly 20-30% of men who have a radical prostatectomy or radiation therapy for prostate cancer will have a rise in their PSA after treatment.  There are multiple options for managing the PSA elevation but they all seem to depend on the answers to three questions:

How long after treatment did the PSA start rising?

How fast does the PSA rise?

What is the Gleason score of the cancer?

If there is a low Gleason score or there is a long delay between the treatment and the first elevation of the PSA and the doubling time of the PSA is greater than one year, then there is not going to be an urgency for manging the rise in PSA.  However, for those men who have a high Gleason score, a PSA that starts to increase in less than three years after treatment and whose doubling time of their PSA is less than 3 months, then this is more worrisome and the men are at high risk of increased morbidity and mortality and needs more immediate management. 

Options.

Radiation can be used after prostate surgery if there is a local recurrence in the prostate gland.  This helps a small number of men but is also associated with side effects.  Men will have the best response if the radiation begins before the PSA is greater than 1.0ng\ml.

The bone scan can help determine if there is spread to the bones.  This test is not useful if the PSA is less than 10ng\ml.

Another form of management is hormone therapy using drugs that shut down the production of testosterone from the testicles.  The options of using hormone therapy incude continuous hormone therapy and intermittent hormone therapy where the drugs are used until the PSA decreases and then follow up with PSA testing every month or two then starting hormone therapy again when the PSA rises.  Intermittent hormone therapy has the advantage of less side effects from the treatment.  The other option is to wait until the PSA significantly rises or that the man becomes symptomatic and then start hormone therapy.  At the present time there is no study or consensus of when to start hormone therapy in men with a rising PSA.  However, if there is a rapid rise in PSA or a doubling time less than three months, these men need treatment sooner. 

Bottom Line: Men have several options for managing the rising PSA after treatment for prostate cancer.  There is no one treatment that works for everybody.  You need to have a discussion with your urologist or your oncologist.