Prostate Cancer FAQs | Dr. Catalona

I recommend that you consider a prostate biopsy procedure that could be performed under
local anesthetic in the office or as an outpatient procedure in the operating room under deep
sedation. You will need to take a Fleet enema the morning of your biopsy and an antibiotic pill 2
hours before your biopsy and a second antibiotic pill at bedtime the evening of the biopsy. You
should be able to return home within an hour or two.

In patients who have undergone radiation therapy, blood in the urine is usually caused by
fragile blood vessels in the bladder that result from the previous radiation treatments (called
“radiation cystitis”. The "proper" evaluation includes a tri-phasic CT scan of the abdomen to
visualize the entire urinary tract and a look into the bladder by passing a small flexible scope
with a tiny camera on its tip up through the urethra (called “flexible cystoscopy”). It also
includes sending urine samples to rule out infection and to look for malignant cells. Usually, the
results are negative. Then, we feel reassured that radiation is the cause and do not pursue
further follow-up unless it occurs again several years later.

For patients whose DEXA scan shows a value lower than -2.5, it is recommended that they have
a bone strengthening treatment. Two of the drugs are zoledronic acid and denosumab. Both
carry some risk of jawbone problems, but this is less with denosumab than the zoledronic acid.
The zoledronic acid also carries a greater risk for kidney damage. Therefore, I recommend that
you consider having denosumab injections. The dosage of the injection is 60 mg every 6
months.

For patients who have any positive margins, the final hurdle is the post-operative PSA. If it is
undetectable, then they have 2 options: (1) to have post-operative radiation therapy to be
proactive (called “adjuvant” radiation therapy), and (2) not to have post-operative radiation
therapy, but to measure the PSA more frequently, i.e., every 4 months rather than every 6
months. Then, if the PSA does begin to creep up, you would get the post-operative radiation
(called “delayed salvage radiation therapy”). The current data suggests that it is okay not to
choose delayed adjuvant radiation therapy unless the pathology findings from the radical
prostatectomy are very severe.

A1a/b:  In times past, we treated patients who had an elevated PSA with antibiotics, even though their urine was not infected. In many patients, the PSA returned to lower levels. However, the infectious disease experts have called this practice “poor antibiotic stewardship," often leading to the bowel becoming colonized with strains of bacteria that are resistant to many different antibiotics. They are correct about this. The current practice is to rely on the patient’s immune system to clear prostatitis without antibiotics. If the PSA does not return to normal, we recommend an MRI and/or biopsy as the next step. Therefore, unless the patient is symptomatic with fever and urinary tract infection, we do not treat with antibiotics.  Nevertheless, once a man has prostatitis, it will likely flare up from time to time.  These flare ups can be expected to be associated with fluctuations in PSA levels.

With those favorable tumor features, the risk for cancer coming back is quite low but not zero. At a minimum, I recommend PSA testing every 6 months for at least 10 years and annually thereafter.

Your Prostate Health Index, total PSA, and percent free PSA are trending in concerning directions: The PSA is rising, the PHI is rising, and the percent free PSA that measures the extent to which your rising PSA is due to a benign condition is decreasing. On the other hand, it is reassuring that you had a negative prostate biopsy less than 6 months ago. Hence, this trend could be the result of persistent inflammation in your prostate from the biopsy procedure. Nevertheless, considering your positive family history of prostate cancer in your father and paternal grandfather, you must remain vigilant. I suggest that you repeat the PHI in 6 weeks to determine whether the unfavorable trend continues, and if so, I recommend a follow-up MRI scan of the prostate to see whether a new region of concern has appeared.

I am glad to learn that your continence is now nearly complete. Most patients stop doing the Kegel exercises once it is 100%, but some continue to do them for the rest of their life. With regard to return of spontaneous erections, the injections may speed up that process. Most patients do not begin to have spontaneous erections for at least a year, but it is best not to wait a year to begin the injections. Start them right away, as this way the chances for complete return are better.

The pills do not materially induce erections until you are beginning to have spontaneous erections, but they marginally increase the blood flow to the genital region. So for patients who don’t want to do the injections, I recommend either the intraurethral suppositories (MUSE – they are very expensive!) or a vacuum device. You can find more information about one such device and how to use it be pasting the following link into an internet browser: https://www.youtube.com/watch?v=hqTpzgcO9nI. Your Prostate Health Index results are trending favorably: i.e., your PSA and PHI are lower but still high, and your percent free PSA is higher (which is good) but not as high as desired. These results are the similar to those 2-3 years ago, so they do not suggest the presence of a continuously growing prostate cancer. I recommend that you repeat the PHI and prostate exam in 6 months.

The vials are intended for multiple uses. You can use the leftover medication, but you should ensure that you use sterile precautions (carefully wiping the vial top and injection site with alcohol) in performing the injection.

For patients who no longer respond to abiraterone/prednisone, the newer-generation apalutamide and darolutamide are frequently effective oral medications and are far better tolerated than enzalutamide.  However, these drugs are prohibitively expensive unless they can be accessed in a clinical trial.

Another new approach that is being increasingly used and championed at Johns Hopkins University by Dr. Sam Denmeade is bipolar testosterone therapy that re-sensitizes castration-resistant prostate cancer to subsequent androgen deprivation therapy.  An added advantage is that most patients become deconditioned (muscle loss, low energy, osteoporosis) by prolonged androgen-deprivation therapy, and the intermittent restoration of testosterone with bipolar testosterone therapy breaks that negative cycle.  Your patient may be able to receive this treatment in your country at a reasonable cost.  I suggest that you and he Google, “bipolar testosterone therapy prostate cancer” for further information.