Catalona Vanderbilt

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RECENT Prostate Cancer QUESTIONS

All questions are answered by Dr. William J. Catalona.

Recent Questions

I have a 68-year old patient with a metastatic Gleason 9 prostate cancer, diagnosed two years ago, that is progressing after hormonal therapy with abiraterone and prednisone and after chemotherapy with docetaxel (6 doses). He is in very good shape. He and his family are interested in traveling to the U.S. for a second opinion and exploring the option of new drugs in a clinical trial. May I ask you for a recommendation?

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.

What is my prognosis when the final pathology report on my prostate gland showed the tumor was organ-confined with clear margins and no seminal vesicle involvement or lymph node metastasis? Does this guarantee that I am “cancer-free?”

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.

How do I interpret my latest test results? It looks as if everything is trending in the wrong direction. My PSA is over a full point higher than it was 6 months ago, and my PHI score seems to be as high as it ever was.

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.

Thanks for sending the MRI test results to me. I guess the prostate sounds ok, but I don’t pretend to understand all of the reports. I guess “poorly distended” in the report means I’m retaining urine? Is there any treatment that could help that? Does “incompletely evaluated” bladder in the report mean they couldn’t see it all?

Your prostate is enlarged at 80 ccs (30 cc is normal), and you have nodules that look typical of benign prostatic hyperplasia in the center that is compromising the flow of urine.  The words, “poorly distended” mean that your bladder was not very full at the time of the exam.  This is good news because it means that you are emptying your bladder.  The bladder is better evaluated for possible tumors on an MRI scan if it is distended with urine. I don’t think you need another exam at this time.  This was just the radiologist’s way of telling me that he/she could not say much about whether there was thickness (meaning a possible tumor) anywhere in your bladder wall.

What is my prognosis when the final pathology report on my prostate gland showed the tumor was organ-confined with clear margins and no seminal vesicle involvement or lymph node metastasis? Does this guarantee that I am “cancer-free?”

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.

How do I interpret my latest test results? It looks as if everything is trending in the wrong direction. My PSA is over a full point higher than it was 6 months ago, and my PHI score seems to be as high as it ever was.

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.

Q1a: I noted that the MRI imaging report also indicates acute “on top of” chronic prostatitis. What treatment do you recommend to address this? Q1b: Is there anything that can be done to treat prostatitis referred to in the report? I believe this is a chronic, long-term issue as I think I recall signs of it in other test reports from the past.

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.

What is my prognosis when the final pathology report on my prostate gland showed the tumor was organ-confined with clear margins and no seminal vesicle involvement or lymph node metastasis? Does this guarantee that I am “cancer-free?”

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.

How do I interpret my latest test results? It looks as if everything is trending in the wrong direction. My PSA is over a full point higher than it was 6 months ago, and my PHI score seems to be as high as it ever was.

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 would rate my urinary continence about 99%. I get an occasional drop but nothing significant. I've made a habit of doing 10 Kegels every morning. My question is, do I need to do these for the rest of my life or was this just for rehabilitative purposes?

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.

I just wanted to let you know I stopped the injections a few months ago, because I don't feel comfortable doing it (having the scar tissue from when I was doing it wrong, along with some bleeding the last few times). If there is a second best alternative you can suggest, I would like to try it or at least consider it. Perhaps, Cialis, Viagra, etc., or something else.

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.

Last night, there was blood in my urine. On occasion, there is also blood in my ejaculate. All of my adult life, I have gotten up about three to four times at night to urinate. Should I be doing something about this?

Blood in the urine or ejaculate is usually caused by fragile blood vessels in the bladder or prostate gland. The “proper” evaluation includes a tri-phasic CT scan of the abdomen to visualize the entire urinary tract, followed by a look into the bladder by passing a small flexible scope up through the urethra to rule out a stone or tumor somewhere in the urinary or genital tract. It also includes sending urine samples for infection and to look for malignant cells. Usually, the results are negative. Then, we feel reassured that the blood may be due to transient inflammation or infection.

FREQUENTLY ASKED Prostate Cancer QUESTIONS & ANSWERS

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Biopsy, Digital Rectal Exam (DRE) & Gleason Score

Initial Treatments After Diagnosis of Prostate Cancer

Conditions After a Radical Prostatectomy

Continence (Urinary Concerns)

Sexual Potency After a Radical Prostatectomy

Post Operative Treatment and Treatment Upon Recurrence

Hormonal Therapy

Information About the Prostate Gland

Other Conditions of the Prostate

Prevention, Nutrition, & Lifestyle

Miscellaneous

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