Catalona Vanderbilt

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Recent Questions

My PSA and Prostate Health Index levels have been trending unfavorably (rising PSA and PHI and decreasing percent free PSA). I am concerned that this may indicate the presence of prostate cancer. Please advise me on the next step in evaluation.

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.

Three years ago, I underwent postoperative salvage radiation therapy for a recurrence of my prostate cancer. Since then, my PSA has been undetectable. Yesterday, after vigorous exercise I noticed some bright red blood in my urine? What should I do?

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.

My DEXA bone density scan reveals moderate osteoporosis (thinning of the bones). Do I need more treatment than the recommended 1000 mg calcium, 1000 units of Vitamin D3, 30 minutes of sunshine without sunscreen daily, and weight-bearing exercise?

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.

The surgical specimen from my radical prostatectomy reported “positive surgical margins.” What should I do about that?

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.

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.

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.

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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