Men With Prostate Cancer Worry Less About Recurrence Than Their Spouses Do

Researchers at The Mount Sinai Medical Center in New York have found that, when it comes to worrying about the recurrence of prostate cancer, male patients worry less than their female spouses or partners. The study was presented at the 30th annual meeting of the Society of Behavioral Medicine in Montreal.

In a study of 96 men and their spouses or partners, Michael Diefenbach, Ph.D., Associate Professor of Urology and Oncological Sciences at Mount Sinai School of Medicine, found that, at the time of prostate cancer diagnosis, the male patients described themselves as "moderately worried" about the chance of their disease recurring, while their female spouses and partners described themselves as "very much" worried.

"We know that illness perception and worries about cancer recurrence influence the emotional well-being of patients. But our studies show that this worry is actually a greater stress on spouses and partners. This research can help us develop programs to address the emotional health of the entire family unit," said Dr. Diefenbach.

For both groups, the concern about recurrence decreased over the next 12 months, though it decreased more for the male patients than it did for their spouses and partners.

This led to an even greater disparity after one year than what was observed at the time of diagnosis, with the men describing themselves as "a little bit" worried and their spouses and partners saying they were "moderately worried."

The study also showed that men were less likely to worry about their cancer recurring if they believed that treatment options for their cancer would be effective, while their spouses' and partners' worries were generally unaffected by outside factors.

"For the male patients, the main driver of worry about cancer recurrence was whether they believed that effective treatment was available for their disease," said Dr. Diefenbach.

"But for their spouses and partners it was not possible to determine the main driver of worry, as their response was mainly an emotional one. The one factor we could really measure that affects the level of spouse and partner worry is age in general, the older the spouse or partner, the more concerned they were about cancer recurrence."

Dr. Diefenbach leads a federally funded research program that aims to improve treatment decision making, patient-physician communication and quality of life through innovative patient and family focused programs. He is also the developer of the Prostate Interactive Education System (PIES), a Web tool that helps prostate cancer patients weigh their treatment options.

Source: Mount Sinai Medical Center

Digital rectal prostate exam a ritual of doctor-patient bonding, for good and bad

The practice, and its awkwardness, will come less often into play as U.S. Preventive Services Task Force guidelines now advise against it for men age 75 and over.

By Anna B. Reisman

November 3, 2008

In August, the U.S. Preventive Services Task Force, a government-sponsored panel of medical experts, issued new recommendations regarding prostate cancer screening: Men ages 75 and over should no longer be screened for prostate cancer with the PSA blood test or digital rectal exam.

An unexpected benefit may be an improvement in the doctor-patient relationship. The rectal exam can be one of the odder moments between a patient and his doctor. Not long ago, for example, I saw a 75-year-old for his routine annual visit. Things were not going well for him.

His wife's dementia was worsening daily. She would leave the stove on, accuse him of stealing her things, holler at him day and night. And yet he could not imagine putting her in a nursing home.

His eyes, usually sparkling with delight, were dull. As I examined his heart and lungs, neck and belly, ankles and feet, he heaved a long sigh. I felt gloomy about his wretched situation.

I must have been preoccupied, because when it was time for the rectal exam, I bumbled my words. I asked him to lower his pants, but instead of saying "Lie on the table," I told him to lie on the floor. The patient and I burst out laughing.

Still chuckling, I stepped out of the room so he could get ready. To be sure, my bumble had brought levity to a traditionally awkward moment -- but why, I asked myself, did this encounter have to end with an examination of his anus?

I was drawn to primary-care medicine by the human connection that comes with the white coat and stethoscope, the prospect of people willing to share their everyday thoughts and deepest secrets, and their expectation that I would use this information to help them.

What I didn't fully grasp was that this intimacy also had a critical physical component -- one that came gloved and lubed.

I'd never imagined that performing rectal exams would become a daily reality. Most of my patients are men over 50, which means that I ask them if they'd like to be screened for prostate cancer.

Some inquire whether the PSA (prostate-specific antigen) blood test alone will suffice. I explain that it's most informative to have both the PSA and the digital exam: Some cancers hide in prostate nodules in men whose PSA readings are normal.

So for men under 75 and over 50 (earlier for higher-risk men) who wish to be screened, just as important as the PSA is the old-fashioned, low-tech way with a pair of rubber gloves, a foil packet of lubricating jelly and an index finger.

For years I didn't feel confident in my ability to do a good rectal exam. In medical school, we spent about two months learning the heart exam, maybe one month on the lungs. The rectal exam was granted a single session.

Not surprising: It's one thing for a parade of students to line up, stethoscopes ready, at the bedside of a chatty patient with a heart murmur; it's quite another to find a patient willing to roll over and endure a series of rectal exams by unskilled, anonymous fingers. The result: a culture of squeamishness.

During residency, I did a lot of rectal exams and tried to get a sense of the prostate's normal size and consistency. But often I wasn't sure of myself. Was a slight asymmetry a normal variant or something worrisome?

I probably sent too many patients to urologists earlier in my career because of my self-doubt, but that was better, I suppose, than missing something.

And although plenty of men will hop onto the exam table without hesitation, there's no shortage of reluctant and nay-saying patients, of awkward silences followed by excuses.

One patient I recall stole a glance at my hands, the muscles in his face relaxing ever-so-slightly when he looked at my fingers. "My old doctor," he said, "had thick fingers, like sausages."

Another said, "My other doctor did one a few months ago, I think." And another, "Next time, I promise." Many opt for the PSA without the rectal exam.

Back in my exam room, the patient lay on the exam table in a fetal position, pants down, buttocks exposed, testicles dangling.

I examined his rectal area for internal hemorrhoids, the subtle edge of an anal fissure, the flat cauliflower of an anal wart, and found none.

I touched the precise spot of the anal skin that elicits the mischievously named "anal wink reflex," a test of nerve function. I dabbed my finger with the jelly and eased it in against the muscular resistance until I touched the prostate.

To feel the whole prostate and distinguish between its two lobes, I bent my knees, turned my arm upside down and swiveled my finger to reach the other side of the gland. It was the size of an apricot, smooth and rubbery.

As usual, I grimaced: The rectum has muscles that clench and unclench at the slightest sensation, and it always feels odd to have my finger locked in that tight embrace. It doesn't get more intimate than this.

Then I closed my eyes and focused on all of the nerve endings packed closely in my fingertip. As my finger swept the prostate gland, I felt its normal consistency, its symmetry and, to my relief, not a single nodule.

It was almost a Zen moment: worlds of otherwise hidden information uncovered through careful probing -- earlier, via conversation; now, via a digit.

I wiped my finger on the stool-sample card and discarded my gloves. The old man looked over his shoulder from the table, the twinkle in his eyes returned. "Does this mean we're friends?"

There's nothing like an awkward joke to defuse an awkward moment. But thanks to the U.S. Preventive Services Task Force, there may now be fewer of both.

My Sentiments Exactly

With a Buzz Cut, I Can Take on Anything

GOT a buzz cut last July, four days before radical open surgery to remove my cancerous prostate. I told family and friends that I did it for reasons of ease and style: I wanted to avoid the heartbreak of hospital hair, that lank and greasy thatch that repels visitors.

But I was lying.

In a time of utter vulnerability — having already weathered three months of post-diagnosis ups-and-downs — I needed the primal ferocity that a buzz cut proclaims. I needed to look like a soccer thug or an extra from “Prison Break” to help get me through surgery, the physical indignities of post-op life, and my subsequent radiation and hormone therapy. I still do. My prostate cancer and its treatment have transformed me — in body and spirit — and the buzz cut has helped me cope with those changes.

I agree with the late Anatole Broyard, who wrote in his memoir “Intoxicated by My Illness,” “It seems to me that every seriously ill person needs to develop a style for his illness.” And the buzz is what I want to wear, what I need to wear, in this wicked waltz with cancer.

I’m an optimist, but not a day goes by in which I don’t wonder whether I’m going to die before I ever imagined. The buzz cut helps me scowl, glower and say “No!” to that thought.

Broyard, a New York Times literary critic who died of prostate cancer, also wrote, “Only by insisting on your style can you keep from falling out of love with yourself as the illness attempts to diminish or disfigure you.”

In some ways, I’ve already fallen out of love with my old self.

There’s a book-jacket photo taken of me early last year, before I learned that I had cancer, and I can’t stand to look at it. Can’t bear to look at my floppy mop of Glen Campbell hair, the innocent grin. I want to smack that cheery and naïve face and bellow: “Boy, you don’t know nothin’!”

That poor guy, at age 50, doesn’t yet know that he has cancer, that it will prove to be shockingly aggressive and that, among other indignities, his libido will take a sabbatical (on Ibiza, I hope).

For me, the buzz cut is a visible bulwark against the tide of emasculating side effects caused by the treatment for prostate cancer.

Wearing my buzz, hiking boots and a rugby shirt, I don’t feel like prey to the cancer. I can still fix my wife with my blue eyes, drop my voice into a Barry White register, and say, “Hey, baby.”

It was only after the fact that I learned that my hair-shearing reaction to having cancer wasn’t so unusual. I understood that the buzz cut spoke of a new me. It still reminds me that I’ve been tempered in the crucible of cancer, that I have changed.

But it’s also part of a muted tradition that’s consistent with the transformation, transition and trauma that I’ve gone through.

Nuns and monks cut their hair, as do saints and rape victims. Soldiers, prisoners and mental patients have their hair cut for them. And issues of hair and appearance are often uppermost in the minds of cancer patients.

“The challenge with cancer is to find a new sense of self,” said Dr. Robert Klitzman, an associate professor of clinical psychiatry at Columbia University Medical Center, “because the narrative of yourself has been disrupted.”

Dr. Klitzman, who has explored issues of serious illness and appearance in several books, most recently “When Doctors Become Patients,” added, “Often, when a woman wears a scarf instead of a wig, she’s owning her cancer, not resisting it.”

That idea of ownership is crucial. My treatment hasn’t made my hair fall out, but partly I wear the buzz to show solidarity with my sisters-and-brothers-in-disease who have no choice.

And the buzz lets me set the social terms of how I face the disease. I’m not interested in the wan and weepy Romanticism of the 19th century in which the patient stoutly wastes away in a soft bed of pity-whispers.

I’m not interested, either, in keeping stoic secrets, in which cancer becomes the fetus of shame buried in the root cellar, or the insane uncle shut in the attic of fear.

Secrets were an epidemic in my rural New Hampshire family — silences about cancer and alcoholism, about bastards and near-bastards — and those secrets and silences killed people.

The buzz grants me the power to look people in the eye and matter-of-factly say: “I have cancer.” Most people who know me will tell you that my current feral style — looking like some vintage N.F.L. middle linebacker — doesn’t reflect my personality.

I am basically a cream puff. But I like the contradiction, the tension, that the buzz cut seems to represent between my inner and outer lives.

The buzz cut is a kind of veil or, perhaps, a mask hiding my secret identities: one of which is being a cancer patient.

But to be honest, I don’t think I’m hiding anyone. We are, all of us, a bundle of apparent contradictions. Even though I’m a dreamy pragmatist, I need the guy with the glare, the shaved skull and the brutishly broad forehead to help me through the day.

I walk into Balonze Barber Shop in Upper Montclair, N.J., every three weeks and tell the owner, Dennis, that I want the “one-zero” buzz, which is even shorter and tighter than the traditional No.1.

As I settle into the familiar chair, Dennis clicks the blade into place, then flicks on the shears. In a way, that chair and the soothing hum of the clippers are just as important a part of my cancer treatment as the TomoTherapy machine in which I received my seven weeks of radiation.

I revel in the smell of alcohol and shaving cream, shiver at the scritch-scratch-scritch of the straight-edge razor on my neck and sideburns. Dennis is preparing me for the next three weeks, the way James Bond gets prepped for a mission.

Besides the faux surface ferocity, the buzz cut also energizes me, puts an extra bounce in my step. And that metamorphosis also carries me back to childhood, when I’d get my summer “whiffle” cut.

So, too, it’s oddly redolent of the Monkees, neighborhood stickaburr fights and going to the stock car races at Star Speedway in Epping, N.H.

In the Bible, Jacob was renamed Israel after wrestling with an angel of the Lord. And, after wrestling with the dark angel of prostate cancer, I, too, have a new name: Cancer Patient and eventually, I hope, Cancer Survivor.

A new name demands a new look, a new style. In my case, it demands the “one-zero” buzz.

The Impossible Calculus of PSA Testing

New York Times editor Dana Jennings writes every Tuesday about coping with an advanced form of prostate cancer.

By Dana Jennings


Prostate cancer and its treatment breed anger and confusion among the men who have it and those who love them. And in the wake of studies released last week that question the value of screening for prostate cancer, I find myself even angrier and more confused.

I’m angry because the two studies confirm my gut feeling – based on comments to this blog and on the stories of many men I know – that millions of men, especially those in their late 60s and beyond, have received unnecessary prostate cancer treatments that have, at the very least, damaged their bodies and lives, if not outright ruined them.

I’m confused because I’m the statistical exception. I’m the one man in 49 whose life may have been saved because I had the PSA blood test. Most prostate cancers are slow and lazy. But my doctors and I learned after I had my prostate surgically removed last July that my cancer was shockingly aggressive. There’s a good chance that it would’ve killed me if I hadn’t been screened. And, to be blunt, it might yet.

Basically, the two large studies – one American, one European – found that screening tests for PSA, or prostate specific antigen, do a great job of discovering prostate cancer. But that knowledge doesn’t translate into many lives saved, the studies state, and for many men it can lead to needless treatment that diminishes quality of life.

My biggest problem with the studies – and, of course, this is the nature of such studies – is that they reduce me and all my brothers-in-disease to abstractions, to cancer-bearing ciphers. Among those dry words, we are not living, breathing and terrified men, but merely our prostate cancers, whether slow or bold.

The most chilling sentence I’ve read in the past week is this one from The New York Times: “In each study, the two groups were followed for more than a decade while researchers counted deaths from prostate cancers, asking whether screening made a difference.”

The researchers counted “deaths,” not men who had died. As Charlie Brown once said to Lucy as she detailed his baseball team’s shortcomings: “Tell your statistics to shut up.”

My own experience with prostate cancer started pretty typically. My PSA was elevated more than a year ago. That fact led to a biopsy last spring, and on April 7 I learned that I had prostate cancer.

It was determined that my cancer was a probable Stage 1, and that my Gleason score was a 6 or 7 on a scale of 10, with 10 being the worst possible number. It appeared that I had an “ordinary” case of prostate cancer. My doctors recommended surgery. In my case, because of previous operations, I had a radical open prostatectomy.

Now, cancer is a powerful card for any doctor to play. Cancer is a serpent in our bodies that we cannot abide. When most of us learn that we have cancer, we want it out right now. We want it annihilated. And for me, surgery was the right decision, because it was only through the post-op pathology report that we learned that my cancer was an aggressive Stage 3 – a T3B – and that my Gleason was an ominous 9. I was actually that somewhat rare man who could die from prostate cancer, not just with prostate cancer. There are still about 30,000 men who die each year from the disease.

Even so, I will still tell you that I was damaged by the surgery, with impotence and incontinence being the major issues; those were also complicated by my follow-up treatments of radiation and hormone therapy.

And given the findings in these two studies, if my case had been typical, if the cancer had been the slow-growth kind and confined to the prostate, I would feel like an absolute fool for having gone through the physical indignities caused by surgery.

Doctors can tell you and tell you that impotence and incontinence are probable side effects. But until you actually experience them as man trying to regain his life, you have no idea what those multisyllabic curses truly mean.

In our competitive medical marketplace, there is no shortage of surgeons out there who aggressively promote themselves and who do a volume business in prostates. But these two studies indicate that maybe that volume should be reduced.

So, I sit here in limbo. And I wonder whether I’ll be that rare man who ducks death from a cancer that would’ve killed him – because I got screened. But all I can confess to you, in all honesty, is this: I’m still angry and confused.

Choosing a Treatment for Prostate Cancer

Once a man is diagnosed with prostate cancer, he faces a myriad of treatment options, ranging from prostate removal to radioactive implants to no treatment at all. Unfortunately, science isn’t much help.

A recent report from the Agency for Healthcare Research and Quality concluded that no one treatment is superior.

As part of our regular health video series, The New York Times spoke with 59-year-old Mark Spindel about his treatment choice: surgical removal of the prostate. Click on the video link to hear his story.

MANAGEMENT OF RADIATION PROCTITIS

Radiotherapy is frequently used in the treatment of cancer inc ombination with other treatments.

In men the two most prevalent cancers requiring radiotherapy are cancer of the bladder and cancer of the prostate.

“As after radical surgery where complications may occur, radiotherapy is not without problems,” reports Dr Chapuis.

Rectal bleeding is a known treatment complication of prostate cancer. Three different terms are used to describe this condition. They are:

•Actinic proctitis

•Radiation proctitis

•Chronic radiation-induced rectal bleeding (CRRB).


Rectal bleeding may complicate treatment in 5 to 10 percent of patients. Rectal bleeding is caused by radiation thickening of the walls of small arteries supplying the rectum, and so by narrowing them to restrict the blood flow to the rectal wall.

To compensate for this, new thread-like capillaries grow in profusion very close to the internal surface of the rectum. It is the fragility of these capillaries that causes the bleeding. As this does not involve true inflammation, “proctitis” is an inappropriate term.

Professor Chapuis prefers the third description: chronic radiation-induced rectal bleeding(CRRB). The rectal bleeding may not start until some 12 months to three years after treatment. Because bleeding is a known side effectof radiation therapy for prostate cancer, and rarely may be life-threatening, patients should be informed of this risk and consent to such treatment.

Rectal symptoms can fall into two broad categories which are partly dose-related: acute and chronic.


Acute:

Symptoms include tenesmus (pain on passing stools), diarrhoea, urgency of defaecation and bleeding.

Chronic:

Symptoms include stricture (narrowing or restriction), fistula (abnormal passage), CRRB, varying degrees of incontinence, loss of compliance and storage capacity of the rectum.


Clinical features of CRRB include:

• It is classed as Grade III on a scale of seriousness from I to IV, ie quite serious. Around 50 percent of cases are late onset (ie, starting later than one year after treatment).

• From a situation with the patient not experiencing any problems, it may become chronic with progressively increasing bleeding resulting in iron deficiency anaemia which may require daily dosage of iron tablets.

• Fifteen to 20 years ago it quite often led to transfusion-dependent anaemia, necessitating frequent blood transfusions, but this is now very unusual as a result of much improved radiotherapy techniques. It is important for prostate cancer patients to recognise that some degree of “collateral” damage will inevitably occur to the rectum due to the radiation treatment.

Late development of bleeding will be experienced by a small proportion of these patients, but this is nowhere near as common or severe a problem as in the past. A critical decision is whether the benefit of the radiation treatment of the cancer outweighs the risks of rectal bleeding or other complications as a result of that treatment.


The factors which affect the risk include:

• The total dose of the radiation

• The fractionation of the dose ie, how it is delivered

• The build of patient, as obese people are more susceptible

• Diabetes

• Hypertension

• Previous abdominal or pelvic surgery (adhesions)

• Chronic diverticular disease of the proximal bowel

• Bleeding may be exacerbated if taking drugs such as Asprin,Warfarin or Plavix Possibly because of their genetic make-up, some men are inherently more sensitive to radiation.


Quality of life issues that may influence the decision whether to opt for/out of radiotherapy include:

• The alarm caused by unexpected bleeds

• The late onset (leading to several years of anxiety about whether bleeding will occur)

• The absence of identifiable risk factors in many cases pre-venting prediction of whether any particular patient will be affected

• Whether the patient has other conditions, such as diabetesor hypertension.


Additional issues include:

• The unpredictable nature of the bleeding which is socially inconvenient and can be acutely embarrassing

• The resulting anaemia is debilitating

• Poor response to treatment

• Simple treatments often pre-scribed (like steroid supposito-ries or enemas) are usually of little benefit

• The condition can last a longtime

• There is a (small) possibility of it progressing to Transfusion Dependent Anaemia.


Patients with CRRB should be thoroughly assessed, including their history and a physical examination, a blood test including a full blood count, iron studies and coagulation profile. Then a safe and thorough examination by colonoscopy of the large bowel enables the severity of the condition to be determined and identification of other sources of bleeding.

A cystoscopy and/or special small bowel X-ray are sometimes appropriate. Sometimes anorectal manometry is needed to test the strength of the sphincter muscle prior to treatment.

The patient may be asked to keep a record of bleeds by marking a calendar as treatment progresses. There are several options for treatment, which will be influenced by the location of the source of bleeding and the extent of the condition.


Minimally invasive therapy includes:

• Electrocautery

• Argon Plasma Coagulation Therapy (APC)

• Endoscopic laser

• Formalin (formaldehyde) dressings applied under a general anaesthetic

• Hyperbaric oxygenation with multiple treatment episodes required.


In the case of APC or endoscopic laser, each potential bleeding pointneeds to be separately treated. The procedure may require several visits, spaced a few weeks apart, to allow the lining of the rectum to recover. The procedure may be undertaken under conscious sedation or general anaesthesia.

The use of formalin began in the1960s. It was found that the formalin destroyed the superficial lining (which then separated off) thus causing the bleeding to stop and allowing the new lining to regrow without blood vessels.

However, the appropriate concentration for the formalin was uncertain, and the approach was abandoned until more recently, when a particular low concentration has been found to be both effective and safe.

A blood count is taken before and after treatment. The patient undergoes a general anaesthetic and is prepared by applying plastic skin dressings applied to the skin surrounding the anal passage. A speculum is inserted and dressings containing formalin are packed into the rectum through it and left for five to ten minutes before being removed. This is repeated until bleeding ceases.


Up to 20% of patients treated with the formalin method experience complications, like:

• Mucus incontinence either from treatment or from the initial radiotherapy

• Some patients may need to wear a pad

• Acute prostatitis (very rare)

• Narrowing of the rectum (veryrare)

• Ischaemic ulcer.

This is pre-vented by taking care to cover exterior of anus with a plastic skin during treatment. Use of either the laser or the formalin method, or both together, results in 75 – 80% success.

However, treatment and follow up may be necessary for up to 12 months. For otherwise intractable cases, several surgical options exist.

Our sincere thanks to Dr Chapuis for his carefully structured presentation and clear explanations, and for fielding wide ranging questions. Summarised by Mark Tweed-dale and Pam Sandoe. Edited and approved by Dr Chapuis; 'The Management of Radiation Proctitis'.

Radiation Proctitis

Radiation Proctitis

The following video depicts one method of treatment used for Radiation Proctitis. Though somewhat graphic, these images show the presence of lesions and how APC (Argon Plasma Coagulation) is used to treat them.

Video courtesy of the Dave Project

Locally advanced prostate cancer: hormone therapy and radiation therapy can double survival.

When prostate cancer extends beyond the prostate but is still contained within the prostate region, it is called ‘locally advanced’. Cancer at this stage is at high risk of progression, but is still potentially curable. This report from a US radiotherapy conference suggests that using two therapies can be better than one alone.

From Medscape Medical News, News Author: Zosia Chustecka

September 23, 2008 — Adding radiation to androgen deprivation therapy in older men with locally advanced prostate cancer reduces the risk of dying from the disease by half. These results, from a randomized clinical trial, suggest that men should be offered this additional option, says lead researcher Anders Widmark, MD, professor in radiation oncology at Umea University in Umea, Sweden.

Dr. Widmark presented the results at a plenary session during the American Society for Therapeutic Radiology and Oncology (ASTRO) 50th Annual Meeting in Boston, Massachusetts.

"This trial will change clinical practice," predicted Anthony Zietman from Massachusetts General Hospital in Boston, who was moderating a press briefing at which the results were highlighted. Dr. Zietman is also president-elect of the ASTRO, taking on the role of president effective September 23, 2008.

"At present, there is a bit of a fatalistic attitude towards locally advanced prostate cancer, as it generally considered to have already quietly spread elsewhere," Dr. Zietman commented. "Often the only treatment often offered to older men with this stage of disease is hormonal therapy," he continued. "This attitude is maybe more common in Europe, but it's also prevalent in the United States."

"The thinking is that the cat is already out of the bag," Dr. Zietman commented, but "the results from this trial prove that this is not the case."

"This randomised trial is the first to show that men with locally advanced prostate cancer will survive substantially longer when radiation is added to their treatment plan," Dr. Widmark told journalists. .

American Society for Therapeutic Radiology and Oncology 50th Annual Meeting: Plenary session. Presented on September 22, 2008.


See: Medscape article

Hormone (Androgen Deprivation) Therapy

Hormone therapy is also called androgen deprivation therapy (ADT) or androgen suppression therapy. The goal is to reduce levels of the male hormones, called androgens, in the body. The main androgens are testosterone and dihydrotestosterone (DHT). Androgens, produced mainly in the testicles, stimulate prostate cancer cells to grow. Lowering androgen levels often makes prostate cancers shrink or grow more slowly. However, hormone therapy does not cure prostate cancer.


Hormone therapy may be used in several situations:

* If you are not able to have surgery or radiation or can't be cured by these treatments because the cancer has already spread beyond the prostate gland
* If your cancer remains or comes back after treatment with surgery or radiation therapy
* As an addition to radiation therapy as initial treatment if you are at high risk for cancer recurrence
* Before surgery or radiation to try and shrink the cancer to make other treatments more effective

Types of Hormone Therapy

There are several types of hormone therapy used to treat prostate cancer.

Orchiectomy (surgical castration): Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where more than 90% of the androgens, mostly testosterone, are made. With this source removed, most prostate cancers stop growing or shrink for a time.

This is done as a simple outpatient procedure. It is probably the least expensive and simplest way to reduce androgen levels in the body. But unlike some of the other methods of lowering androgen levels, it is permanent, and many men have trouble accepting the removal of their testicles. Some men having the procedure are concerned about how it will look. If wanted, artificial silicone sacs filled with saline (salt water) can be inserted into the scrotum. These look and feel like testicles.

Possible side effects of orchiectomy are generally related to changing levels of hormones in the body. About 90% of men who have had this operation have reduced or absent libido (sexual desire) and impotence. Some men also experience:

* Hot flashes (these may go away with time)
* Breast tenderness and growth of breast tissue
* Osteoporosis (bone thinning) which can lead to broken bones
* Anemia (low red blood cell counts)
* Decreased mental acuity (sharpness)
* Loss of muscle mass
* Weight gain
* Fatigue
* Decrease in HDL ("good") cholesterol
* Depression

Many of these side effects can be prevented or treated. For example, sometimes the hot flashes will be helped by treatment with antidepressants. Brief radiation treatment to the breasts before surgery can help prevent their enlargement.

Men getting this treatment should be watched and treated for osteoporosis to help prevent broken bones. There are several different drugs available. Exercise is a good way to reduce fatigue, weight gain, and the chance of loss of bone and muscle mass. If anemia occurs, it is often very mild and usually doesn't cause symptoms. Depression can be treated by antidepressants and/or counseling.

Luteinizing hormone-releasing hormone (LHRH) analogs: Even though LHRH analogs (also called LHRH agonists) cost more and require more frequent doctor visits, most men choose this method over orchiectomy. These drugs lower testosterone levels just as well as orchiectomy by lowering the levels of androgens (mainly testosterone) made by your testicles.

LHRH analogs are injected or placed as small implants under the skin. They are given either monthly or every 3, 4, 6, or 12 months. The LHRH analogs available in the United States include leuprolide (Lupron, Viadur, Eligard), goserelin (Zoladex), and triptorelin (Trelstar).

Possible side effects of LHRH analogs such as hot flashes, osteoporosis, and others are similar to those of orchiectomy (see above), and are largely due to low testosterone levels.

When LHRH analogs are first given, testosterone production increases briefly before falling to very low levels. This effect is called flare and results from the complex way in which LHRH analogs work. Men whose cancer has spread to the bones may experience bone pain. If the cancer has spread to the spine, even a short-term increase in growth could compress the spinal cord and cause pain or paralysis. Flare can be avoided by giving drugs called anti-androgens for a few weeks when starting treatment with LHRH analogs. (For more on anti-androgens, see below.)

Luteinizing hormone-releasing hormone (LHRH) antagonists: A newer drug, abarelix (Plenaxis), is an LHRH antagonist. It is thought to work like LHRH agonists, but it appears to reduce testosterone levels more quickly and does not cause tumor flare like the LHRH agonists do.

A small percentage of men (fewer than 5%) have serious allergic reactions to the drug. Because of this, it is only approved for use in men who have serious symptoms from advanced prostate cancer and who cannot or refuse to take other forms of hormone therapy.

The possible side effects are similar to those with orchiectomy (see above) or LHRH agonists.

Abarelix is given only in qualified doctors' offices. It is injected into the buttocks every 2 weeks for the first month, then every 4 weeks. You will be asked to remain in the office for 30 minutes after the injection to make sure you are not having an allergic reaction.

Anti-androgens: Anti-androgens block the body's ability to use any androgens. Even after orchiectomy or during treatment with LHRH analogs, a small amount of androgens is still made by the adrenal glands.

Drugs of this type, such as flutamide (Eulexin), bicalutamide (Casodex), and nilutamide (Nilandron), are taken daily as pills.

Anti-androgens are not often used by themselves (see below). An anti-androgen may be added if treatment with orchiectomy or an LHRH analog is no longer working by itself.

Anti-androgen treatment may be combined with orchiectomy or LHRH analogs as first-line hormone therapy. This is called combined androgen blockade (CAB). There is still some debate as to whether CAB is more effective in this setting than using orchiectomy or an LHRH analog alone. If there is a benefit, it appears to be small.

Some doctors are testing the use of anti-androgens instead of orchiectomy or LHRH analogs. Several recent studies have compared the effectiveness of anti-androgens alone with that of LHRH agonists. Most found no difference in survival rates, but a few found anti-androgens to be slightly less effective.

If hormone therapy including an anti-androgen stops working, some men seem to benefit for a short time from simply stopping the anti-androgen. Doctors call this the "anti-androgen withdrawal" effect, although they are not sure why it happens.

Side effects of anti-androgens in patients already being treated by orchiectomy or with LHRH agonists are usually not serious. Diarrhea is the major side effect, although nausea, liver problems, and tiredness can also occur.

The major difference from LHRH agonists and orchiectomy is that anti-androgens may have fewer sexual side effects. When these drugs are used alone libido and potency can often be maintained.

Other androgen-suppressing drugs: Estrogens were once the main alternative to orchiectomy for men with advanced prostate cancer. Because of their possible side effects (including blood clots and breast enlargement), estrogens have been largely replaced by LHRH analogs and anti-androgens. Still, estrogens may be tried if androgen deprivation is no longer working.

Ketoconazole (Nizoral), first used for treating fungal infections, blocks production of androgens and is sometimes used.


Current Controversies in Hormone Therapy

There are many issues around hormone therapy that not all doctors agree on, such as the best time to start and stop it and the best way to give it. Studies looking at these issues are now under way. A few of the issues are discussed here.

Early vs. delayed treatment: Some doctors think that hormone therapy works better if it is started as soon as possible if the cancer has reached an advanced stage (for example, when it has spread to lymph nodes), if it is large (T3) or has a high Gleason score, or if the PSA starts rising after initial therapy, even though the patient feels well. Some studies have shown that hormone treatment may slow down the disease and perhaps even lengthen patient survival. But not all doctors agree with this approach. Some are waiting for more evidence of benefit. They feel that because of the likely side effects and the chance that the cancer could become resistant to therapy sooner, treatment should not be started until symptoms from the disease appear. Studies addressing these questions are now under way.

Intermittent vs. continuous hormone therapy: Nearly all prostate cancers treated with hormone therapy become resistant to this treatment over a period of months or years. Some doctors believe that constant androgen suppression may not be needed, so they advise intermittent (on-again, off-again) treatment.

In one form of intermittent therapy, androgen suppression is stopped once the blood PSA level drops to a very low level. If the PSA level begins to rise, the drugs are started again. Another form of intermittent therapy involves using androgen suppression for fixed periods of time -- for example, 6 months on followed by 6 months off.

Clinical trials of intermittent hormonal therapy are still in progress. It is too early to say whether this new approach is better or worse than continuous hormonal therapy. However, one advantage of intermittent treatment is that for a while some men are able to avoid the side effects of hormonal therapy such as impotence, hot flashes, and loss of sex drive.

Combined androgen blockade (CAB): Some doctors treat patients with both androgen deprivation (orchiectomy or an LHRH agonist) and an anti-androgen. But most doctors are not convinced there's enough evidence that this combined therapy is better than one drug alone.

Triple androgen blockade (TAB): Some doctors have suggested taking combined therapy one step further, by adding a drug called a 5-alpha reductase inhibitor -- either finasteride (Proscar, Propecia) or dutasteride (Avodart) -- to the combined androgen blockade. There is very little evidence to support the use of this "triple androgen blockade" at this time.

Last Revised: 08/25/2008

Radiation Therapy - Week Three

DAY ONE

Today I arrived at the hospital to find that treatment would be late. This allowed me to have extra time with the Radiation Oncologist's Registrar - the former was on leave. The regular weekly review is very important for many reasons, chief among them (for me) is that such such sessions allow me to ask as many questions as i like!

Unlike last week, I was prepared this week with a list of question that I had written down - taken essentially from the (hand written) diary that I keep. This diary is also the source of much of what appears on this blog. I find keeping the diary invaluable, as these days I can't rely on my memory - one of the side effects of the treatment I'm on!

In case you're interested, here is this week's list of questions:

1. A reminder (to the doctor) that I should have had a 'liver function test' weeks ago! This I knew ONLY because of my own research! Oh ... ah ... YES let's do that today. (The pathology request was marked URGENT). When you have no 'Case Manager' looking at your treatment from a 'holistic perspective', your treatment can suffer; as the various specialists tend to focus (mostly) upon their own field of expertise - therefore 'things' can be missed!


2. What can I do about the increased fatigue and subsequent breathlessness? I'm afraid there's not much we can do about that. But you should begin to tolerate that portion that can be attributed to the Radiation in about another week or so.


3. What about the 'confusion and memory loss'? You have so much 'on your plate' right now; it's no wonder you suffer a bit in this area!


4. My weight gain (9kg) concerns me is there anything you can suggest? I'm afraid not ... it goes along with the treatment ... particularly the Hormone Treatment.


5. In that case would you think that seeing a Nutritionist is advisable? Yes ... I think this is an excellent idea. I'll ring through now to obtain an appointment.


6. Night time urinations have actually increased despite being prescribed 'Flomaxtra'? We might have to double your dosage. My research tells me that Flomaxtra doesn't really kick in for about 7 days; and since this is day 7, would you suggest we wait another week? Yes that would be very sensible.


7. I am currently on holidays do you think I'll be up to a return to work on the 16 April - in the middle of my Radiation Treatment? We'll really have to wait and see ... but if we feel you're not ready (for work) I would be happy to write you a certificate to that affect.


8. Would one month after my treatment finishes be too soon to fly overseas - to live? Again we really need to wait and see, but I would imagine that that would be fine.


9. I'll be on the LHRH Analogues for 2-3 years ... will I need to be on the Anti-agonist that long as well? (My research said YES). I'm afraid so ... but I'm sure that you'll be fine.


10. I have had a bout of the 'flu for a week now, is it OK to take some cold and 'flu tablets to relieve the symptoms until the virus is defeated? Yes, that'll be OK.

With pathology request in hand, I then went in search of my favourite nurse - Nurse Judy. Not only was she able to point me in the right direction, she was also able to 'take the blood'. Mission accomplished! I then felt that we were getting somewhere.

Now off to my Radiation Treatment ... I'll ask if they're ready for me yet!

Oh, I almost forgot ... I was finally given my actual 'staging result' today - after repeated requesting.

The result ... T3N0M0. In order to understand this result better, my next post will seek to explain what 'staging' means in relation to Prostate Cancer.

Radiation Therapy - Week Two

DAY ONE

Well today I started my second week of Radiation Treatment (R/T). At the beginning of each new week, patients routinely review their progress regarding the previous week's treatment with their Radiation Oncologist.

While awaiting my turn to see the Radiation Oncologist, I couldn't help but notice the enormous volume of 'patient files' arrayed behind me!

At present, the Radiation Oncology Department is running at only 'two thirds capacity' as one of the Linear Accelerators is being replaced with a latest: 'state of the art machine'. Even so, the Radiation Oncology Department sees between 100 and 110 patients per day!!

Weekly Review

The appointment with my Radiation Oncologist went well, although it is very early in my treatment to expect any major indications 'one way or the other'. After a discussion re the range of side effects I'm contending with, and weighing the pros and cons of each medication etc; it was decided that no change of my current medications was required.


New Medication

However, we did decide that since I was getting up to urinate at least 3 times every night; that this, should be targeted in terms of possible relief. With that in mind, I was prescribed 'Flomaxtra' which hopefully will cut the trips to the toilet down to one or two at most.


Flomaxtra

When you pass urine, the urine travels from the bladder through the urethra which runs through the prostate. When the prostate gland becomes large, the urethra becomes narrow. The urethra may even become blocked. If this happens, no urine can be passed. This is a medical emergency!

FLOMAXTRA(R) is a medicine which relaxes smooth muscle, especially in the prostate. Which allows the urethra to expand to its normal size. This in turns allows the urine to flow more naturally.


Side Effects

Most men prescribed FLOMAXTRA(R) benefit. As with any medicines, some side effects may occur. FLOMAXTRA(R) does not usually cause any problems. If you develop a skin rash, itchiness or swelling of the face, lips or tongue, tell your doctor immediately, as you may be having an allergic reaction to FLOMAXTRA(R).

Swelling of the face, lips or tongue may cause difficulty in swallowing or breathing. One side effect of FLOMAXTRA(R)is known as "retrograde ejaculation". When this happens the ejaculation fluid is not squirted out, most of it runs back into the bladder. Retrograde ejaculation is painless. Other side effects reported by people taking FLOMAXTRA(R) include dizziness, headache, itching, weakness, dizziness on standing, nausea, vomiting, diarrhoea, constipation, rash, fast heart beats and blocked nose.

FLOMAXTRA(R) can occasionally cause people to feel faint and dizzy. You should get up slowly from the sitting or lying position to reduce the risk of dizziness or light-headedness. If you do feel faint on standing up, you should lie down for a short while. If the dizziness persists you should contact your doctor. You must not drive a car or operate machinery if you feel dizzy. This is not a complete listing.

Other unwanted effects may occur in some men. Tell your doctor if you notice any other effects or if the unwanted effects are particularly bothersome. You should always tell your doctor about any problems you have whilst taking FLOMAXTRA(R).

Side Effects

When is enough ... enough? In my case, when the Oncologist says so!

Reviewing my diary over the past couple of weeks, I had noticed that the number of side effects and the impact that they were having was increasing to the point of concern.

And so, a phone to my Oncologist soon confirmed what I had suspected. The Anandron was not a good option for me!

The past week in particular revealed that the side effects had resulted in:

• Dry mouth
• Increased hot flushes
• Increased fatigue
• Photo-sensitivity, and
• Nausea

The solution ... to immediately stop the Anandron and to commence Androcur (Cyproterone).

Unlike Anandron, Androcur is a steroidal antiandrogen. Cyproterone is available as an oral (by mouth) tablet and as a long-acting injectable. The recommended dose for cyproterone tablets is 200 mg to 300 mg (4 to 6 tablets) daily, divided into 2 to 3 doses and taken after meals. In my case, the recommended dose was 300 mg per day.

Imagine my delight when I read the list of possible side effects associated with Androcur ...

The following side effects have been reported by at least 1% of people taking this medication. Many of these side effects can be managed, and some may go away on their own over time.

Contact your doctor if you experience these side effects and they are severe or bothersome. Your pharmacist may be able to advise you on managing side effects.


More common:

• impotence
• reduced (or increased) sexual interest
  swelling of the breasts or breast soreness

Less common or rare (0% to 10%)

• changes in walking and balance
• clumsiness or unsteadiness
• hair loss
• inability to move legs or arms
• increased sensitivity of skin to sunlight
• increase in bowel movements and loose stools
• loss of strength or energy
• skin bleeding, blistering, coldness, or discoloration
• unusual increase in hair growth
• weight gain

Although most of the side effects listed below don't happen very often, they could lead to serious problems if you do not seek medical attention. Check with your doctor as soon as possible if any of the following side effects occur:


Less common or rare (0% to 10%)

• abdominal pain or tenderness
• back pain
• blisters
• blurred vision
• chest pain
• chills
• clay colored stools
• confusion
• cough
• depression
• dizziness
• drowsiness
• dry mouth
• fainting or light-headedness when getting up
• fast heartbeat
• hallucinations
• hives
• increase in blood pressure
• increase in hunger and/or thirst
• lower back or side pain
• nausea and vomiting
• painful or difficult urination
• red, thickened or scaly skin
• shortness of breath
• skin rash
• sores, ulcers or white spots on lips or in mouth
• sore throat
• stiff neck
• stomach ache
• swollen and painful glands
• tightness in chest
• unexplained weight loss
• unusual bleeding or bruising
• vision changes
• wheezing
• yellow eyes or skin

Get immediate medical attention if any of the following side effects occur:


Less common or rare (0% to 10%)

• bloody or black, tarry stools or blood in urine
• irregular breathing
• pains in chest, groin, or legs, especially calves of legs
• puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue
• seizures
• sudden and severe weakness in arm and/or leg on one side of the body
• sudden loss of coordination
• sudden slurred speech
• temporary blindness

Some people may experience side effects other than those listed. Check with your doctor if you notice any symptom that worries you while you are taking this medication.

The 'saving grace' ... in all of this for me ... I was on this medication for 4 weeks at the commencement of my Hormone Therapy, and survived quite well!

Finally some Answers

Today, I took myself off to the Radiologist's surgery; armed with a page full of questions - the same questions that the Urologist (Dr J) avoided (for the most part). The questions looked something like this:

• What if anything, can be done about the fatigue?
  


• Should I be concerned about the 'shortness of breath'?
  


• What about the dizziness?
  


• Should we consider addressing the cholesterol level at this time?
  


• What about the ... 'blood in the ejaculate'?
  


• What can I do about the 'hot flushes'?
  


• Um ... ah ... what about ... um ... 'breast tenderness'?
  


• Is the weight gain something to concern myself about at this time?
  


• And the blood in the ejaculate?

Well here are the answers - hot off the press!

• What if anything, can be done about the fatigue? Hopefully I will learn to tolerate this unwanted side effect otherwise medication can be used.
  


• Should I be concerned about the 'shortness of breath'? Worst case, this could point to 'heart related issues' but having 'pretty much' ruled that out, and since this side effect seems to be waning ... we'll press on.
  


• What about the dizziness? This can be caused by any number of things and will be monitored.
  


• Should we consider addressing the cholesterol level at this time? Yes.
  


• What about the ... 'blood in the ejaculate'? This is possibly the result of the 16 core samples taken during the TRUS, 3 and a half months ago, or is related the the tumour itself. Either way it doesn't affect the treatment under consideration.
  


• What can I do about the 'hot flushes'? Again, I should be able to tolerate these, particularly with winter around the corner! However, there are medications that can help with this also.
  


• Um ... ah ... what about ... um ... 'breast tenderness'? If this becomes too bothersome, we can 'zap it' with some radiation and 'VOILA' problem solved (fried?).
  


• Is the weight gain something to concern myself about at this time? It could be ... but we'll see how things go. Diet, exercise and perhaps some weight training offer the best outcomes. [Currently all the above apart from 'weight training' are in play!]
  


• And the blood in the ejaculate? This is to be expected, but again will not affect the proposed treatment.

Prostate 'Gold Seeds' Improve Radiation Treatment

Today I attended my first appointment with the newest member of my healthcare team - 'Dr T' - my Radiation Oncologist. The appointment lasted for over 90 minutes - I finally got to ask, and have answered, ALL of my questions!!

Firstly, I want to talk about the 'new' technique that I will be undergoing in terms of my radiotherapy - sometimes referred to as 'gold seed technology'.

Gold seed technology is a fairly recent innovation in Australia and is only available in a (very) limited number of places. Fortunately for me, my radiologist is one of the few 'experts' who not only possess such technology, but have become very conversant with it's usage.

Now, some history...


November 2005

A new treatment method for prostate cancer patients undergoing radiation therapy that more accurately and effectively targets the cancer while minimizing side effects is now available in Australia.

Fiducial markers, or "gold seeds," are non-radioactive markers that are placed in the prostate. Because it is natural for the prostate to move around in the pelvic cavity, depending on how much liquid a patient has consumed and other factors, it can be challenging to locate the prostate precisely during radiation therapy.

Unlike brachytherapy, which uses radioactive seeds to treat the cancer, gold seeds simply allow the prostate's location to be tracked on a daily basis using X-ray imaging to ensure treatment accuracy. Only a handful of health care organizations offer this treatment in Australia.

Previously, physicians had to leave a margin of error when locating the cancerous tissue because it was difficult to target the exact location of the prostate before the gold seed technology emerged. During this process, healthy tissue may have been exposed to radiation.

Gold seed technology allows the physician to know exactly where the prostate is at any given time. Therefore, a higher dose of radiation can be delivered to a more precise area, while minimizing exposure to nearby healthy tissues.


Gold Seeds Help Pinpoint Prostate Cancer

WCVB-TV 04.07.2006

BOSTON -- Prostate cancer is the most common cancer among American men. One in six men will be diagnosed with the disease in his lifetime.

NewsCenter 5's Heather Unruh reported Friday that treating it can be tricky -- even a slight movement of the prostate can alter the effectiveness of radiation and potentially damage healthy tissue.

Now, doctors at Mount Auburn Hospital are using new technology to pinpoint prostate cancer with the help of some very tiny but very precious metals.

A tiny gold seed is helping doctors treat Joe Crowley's prostate cancer.

"I feel good about the treatment," Crowley said.

The gold seeds are actual gold, but they are not radioactive. Instead, they serve as markers for radiologists attempting to locate and treat the often hard-to-target prostate.

"In the past, our solution was very simple. You simply enlarge the area you're treating to make sure the target is going to be fully covered by the radiation -- but in the process, we were exposing more normal tissue to the radiation and increasing the risk of injury," Mount Auburn Hospital's Dr. Anthony Abner said.

With Gold Seed technology, [a number of] seeds are placed around the prostate. Using X-ray imaging, doctors can then monitor the location of the seeds. If the seeds have moved, the prostate has moved, and they can alter the radiation accordingly.

"The benefit is that we can dramatically reduce the amount of normal tissue that's hit by the radiation. By doing so, we can actually use higher doses of radiation with better cure rates," Abner said.

The treatment is less painful and more accurate than other options, such as balloon dilation and ultrasound. But it does require almost daily monitoring, which means many trips to the radiologist -- a price Crowley said he is willing to pay.

"It's a little lengthy, but I think I have 34 treatments, but hopefully they'll go by fast and I'll pick up where I left off," Crowley said.

While it's too soon to know exactly how much Gold Seed technology is improving prostate cancer outcomes, doctors said that patients report feeling better during treatment, having fewer side effects and fewer long-term complications.


The implications for me are ...

• I can benefit from the higher doses of radiation , without the risk of 'other organ damage'!


• I can also receive a variation of the 'whole-pelvic' treatment described in an earlier post - safely.

We'll look at this in more details in my next post.

Prostate cancer survival improved with whole-pelvic radiation plus hormone therapy

Abstract

Patients with localized prostate cancer who have a 15% estimated risk of lymph node involvement and an elevated prostate-specific antigen level are good candidates for whole-pelvic radiotherapy plus neoadjuvant and concurrent hormonal therapy.


Complete Article - 16 Jun 2003

These are the findings of a phase III study involving 1323 such patients reported by Dr. Mack Roach III of the University of California in San Francisco and colleagues in the May 15th issue of the Journal of Clinical Oncology.

"This trial tested the hypothesis that combined androgen suppression and whole-pelvic radiotherapy followed by a boost to the prostate improves progression-free survival by 10% compared with combined androgen suppression and prostate only prostate-only radiotherapy," they explain. "This trial also tested the hypothesis that neoadjuvant and concurrent hormonal therapy improves progression-free survival compared with adjuvant hormonal therapy adjuvant hormonal therapy by 10%," they further explain.

According to the team, whole-pelvic radiotherapy was associated with a 4-year progression-free survival of 54% compared with 47% for prostate-only radiotherapy (p = 0.022). Patients treated with neoadjuvant and concurrent hormonal therapy had a 4-year progression-free survival of 52% versus 49% for adjuvant hormonal therapy (p = 0.56).

Compared with the other treatment, the combination of whole-pelvic radiotherapy plus neoadjuvant and concurrent hormonal therapy was associated with the longest progression-free survival (60%).

"This study proves that there is a favorable biologic interaction between whole-pelvic radiotherapy and neoadjuvant and concurrent hormonal therapy, but no advantage to short-term neoadjuvant and concurrent hormonal therapy compared with short-term adjuvant hormonal therapy when only the prostate is irradiated," the investigators conclude.

The benefits of whole-pelvic radiotherapy plus neoadjuvant and concurrent hormonal therapy in the lymph nodes "should not be completely surprising," they add. "Occult lymph node involvement despite negative imaging is a well-recognized problem in patients with prostate cancer, and prophylactic nodal radiotherapy has been shown to prolong survival in women with breast cancer," they add.

(Source: J Clin Oncol 2003;21:1904-1911: Reuters Health: June 13, 2003: Oncolink)

Hormone Therapy and Radiotherapy Combined

As mentioned in my last post, further good news, was received concerning my ongoing treatment and came in the form of a 'green light' to commence radiotherapy ASAP. Originally, it was planned that I would have two consecutive implants (duration of 6 months) and then, providing the PSA level was at an appropriate level, we would the consider radiotherapy.

The upshot of the visit was, that we now move into a new phase of treatment - 'Radiotherapy' (RT) as an adjunct to the Hormone Therapy (HT). The latter will most likely continue for approximately 18 to 24 months. However, there is a possiblity that I could be on HT for the remainder of my life; dependent upon the success of the radiation treatment.

[It has also been decided at this stage, to rule out surgery; because of the likely complications; both during and after the operation].

Radiation Therapy will entail daily radiation treatment, 5 days a week for approximately 6 weeks; (with Saturday and Sunday ... 'off for good behaviour').

Unfortunately this will also involve short stays in hospital for each subsequent treatment; thus further complicating my desire to lead as normal a life as possible e.g. juggling work committments, cancer therapies and home and social life etc.


Hormone Therapy

It has long been known that once prostate cancer develops, the male hormone testosterone, produced by the testicles, is closely involved in stimulating the cancer’s growth and spread. Earlier treatments for the disease often involved removing the testicles surgically to reduce testosterone production by the body. Now products are available that can be taken in the form of tablets or injections to suppress testosterone even more effectively. The process is known as hormone therapy.

Hormone therapy is often used to shrink the prostate and the tumour before commencing radiotherapy. It is now quite common for a course of hormone therapy to be administered after primary treatment by radiation or surgery, particularly if there is evidence that the tumour may have spread beyond the capsule (tissue immediately surrounding the prostate). There is emerging evidence that better outcomes are being achieved from these combined techniques.

If the prostate cancer has already spread to other organs or to bone at the time of diagnosis, hormone therapy becomes the primary method of treatment. Monthly or three monthly injections, possibly also accompanied by tablets, are used to try to reduce the PSA reading as close as possible to zero. Most advanced cancers respond well to hormone therapy for several years. Some doctors apply the therapy intermittently - six or twelve months on treatment then some months off - known as "pulsing". This gives the patient some respite from side effects and may extend the period of effective treatment, although this has not been proved.

The advantages of hormone therapy are that it is simple to administer. The disadvantages are the side effects, which can be distressing. They include hot flushes, loss of libido and erections, sweating, mood swings, disturbed sleep, loss of energy and personal motivation, body hair loss, bone loss, weight gain and breast development or tenderness. Unfortunately, most advanced cancers eventually become resistant to hormone therapy, after which the disease resumes its progress.


Radiation

Radiotherapy involves the use of various types of X-rays to treat cancer.

External beam radiotherapy (EBRT) has been the traditional method of delivering the radiation. Short pulses of tightly focused beams of X-rays are delivered from outside the body into the prostate for a few minutes each day. Treatment continues five days a week for seven weeks. Conformal Radiotherapy, allows the X-rays to be directed very accurately to the prostate in three dimensions. EBRT has a track-record of success in "curing" cancers confined to the prostate that is very close to that of surgery.

From a patient’s perspective, the advantages of EBRT are that it is less intrusive and stressful than surgery, with no risk of infection. It particularly suits older men or those with fitness or other health problems that make the risk of surgery greater. The disadvantages are that time for treatment is much longer and may involve travel and accommodation problems, particularly for country patients. Radiation can damage other organs, particularly the bowel and bladder.

Irritation of the bowel is a common side effect that can trouble patients for six months or longer after treatment. Rates of occurrence of incontinence and impotence are similar to surgery, but tend to occur later. With radiotherapy up to 50% of men develop erection problems and many develop mild to moderate inflammation of the bowel, although only approximately 3% of men develop severe, ongoing bowel problems. It is also important to mention that it is not uncommon after radiotherapy to develop a change in bowel habit, with looser and more frequent bowel movements, increased flatus and possible bleeding.

Once again, the skill, experience and result record of the radiotherapist and standard of the treating equipment are paramount to the outcome. Intending patients should enquire carefully into these matters before making a selection.

After treatment you will have further PSA tests to monitor developments. Your PSA should gradually reduce over about 12 months to between 1 and 2. If it fails to reduce to these levels, your doctor may recommend further treatment, probably by hormone therapy. However, regardless of the post-treatment movement of the PSA reading, it is quite common for doctors to recommend hormone therapy immediately after radiation as part of the total treatment.

Robotic Surgery

Further Research

I thought since I have already jumped ahead a few months by beginning to explore the various methods of 'radiotherapy'; that I may as well 'jump' to the next step, following that: i.e. 'Removal of the Prostate'. My surgeon intends to use the 'laporascopic method', rather than the more common 'open surgery' method. Whilst exploring these various options, I came across a radical, new technique now being used in Australia (and elsewhere).


The da Vinci PROSTATECTOMY Method

Da Vinci Robotic prostatectomy is the newest and most advanced surgical option for patients. This method gives a surgeon greater visualization, enhanced dexterity, precision, control and superior ergonomics. This very precise surgery only requires 5 small incisions (1cm) in the abdomen.


About the da Vinci Robotic System

The da Vinci Surgical System is powered by state-of-the-art robotic technology. The System allows your surgeon's hand movements to be scaled, filtered and translated into precise movements of micro-instruments within the operative site. The magnified, three-dimensional view the surgeon experiences enables him to perform precise surgery in complex procedures through small surgical incisions.

The da Vinci System enhances surgical capabilities by enabling the performance of complex surgeries through tiny surgical openings. The System cannot be programmed nor can it make decisions on its own. The da Vinci System requires that every surgical maneuver be performed with direct input from your surgeon. The da Vinci Surgical System has been successfully used in thousands of prostate cancer procedures world-wide.





For patients, there are numerous potential benefits including:

• Shorter hospital stay


• Less pain and less pain medication


• Less risk of infection


• Less blood loss


• Less scarring


• Faster and more complete recovery


• Quicker return to normal activities

Surgical Benefits:

• 3-D visualization provides the surgeon with a true 3-dimensional view of the operating field. This direct and natural hand-eye instrument alignment is similar to open surgery with all-around vision and the ability to zoom-in and zoom-out.


• Dexterity: the da Vinci Robotic System provides the surgeon with intuitive operative controls that allows the experienced surgeon to use his open surgery skills rather than having to use counter-intuitive motions typically required by a laparoscopic approach.


• Surgical Precision: permits the surgeon to manipulate instruments with such accuracy that the current definition of surgical precision is exceeded.


• Range of Motion: the robotic instruments offer the surgeon full range of motion and ability to rotate the instruments through tiny incisions.


• Ergonomics: the surgeon can sit in a comfortable position, allowing him to concentrate fully on the surgery.


• Improved Access: Surgeons perform complex surgical maneuvers through 1-cm ports, eliminating the need for large traumatic incisions.

Source: St Vincent's Clinic

Radiotherapy

Since my next challenge (after a successful 6 consecutive months of Hormone Therapy - in 4 months time) will be to undertake an 8 week course of Radiotherapy; I thought it prudent to take a closer look at the whole process.


Radiotherapy for Prostate cancer

Radiotherapy is a form of treatment that is used to treat cancer of the prostate gland. It may be used alone or in conjunction with surgery.

Radiotherapy involves the use of radiation which is targeted to the cancer site in order to destroy cancerous cells. Treatment is planned meticulously in order to minimise harm to normal cells. Treatment is usually carried out as an outpatient procedure, and lasts for several weeks (depending on the nature of the tumour).

There are different forms of radiotherapy for the prostate available.

Radiotherapy fights cancer by using high energy radiation to destroy cancer cells that multiply rapidly. It prevents the cancer cells from multiplying and stops the cancer from growing larger. It is a commonly recommended form of treatment as it is less invasive than surgery, and does not carry as many risks as surgery does.

During radiotherapy, patients will lie on a couch under a large x-ray machine. Each treatment lasts only for a few minutes and is not painful.


Forms of Radiotherapy

There is a wide range of forms of radiotherapy in treating cancer of the prostate:

1. External beam therapy:

• Divided into Standard External Beam Therapy and 3D Conformal Therapy.
  


• It delivers radiation beams targeted to the prostate.



• It is carried out as an outpatient procedure - patients do not have to stay in the hospital.



• 3D Conformal Therapy is a more updated method but is less widely available. It uses beams that are shaped to the outline of the prostate. Computer images are used to target the beams accurately.

2. Brachytherapy:

• It is a form of radiation therapy used in more localised prostate cancer, meaning cancer that is more confined to the prostate itself.
  


• In brachytherapy, the doctor implants radioactive seeds directly into the prostate.
  


• This enables the radiation to be given at a higher dose in a more concentrated manner.
  


• It is a fairly short procedure. Patients are usually required to stay in the hospital for only one night.

3. High Dose Rate (HDR) brachytherapy:

• It is usually combined with external radiotherapy.
  


• It is used to treat more advanced prostate cancer, where treatment is needed to cover the whole prostate and a margin.
  


• In HDR brachytherapy, thin stiff plastic tubes are inserted through the perineum (the area of skin behind the scrotum) and into the prostate. This is done under anaesthesia.
  


• A radiotherapy machine inserts a radioactive wire through each plastic tube and into the prostate. These wires are left in place for a few minutes and then removed.
  


• Patients stay in the hospital for one night. The next day the procedure of inserting and removing the radioactive wires is repeated. The procedure takes about half an hour.

HDR machine: The machine used in High Dose Rate (HDR) brachytherapy to insert radioactive wires through plastic tubes into the prostate. This is often used to treat prostate cancer at an advanced stage.

The Seeding Procedure:

The procedure in brachytherapy where radioactive seeds are implanted into the prostate to destroy cancer cells.

Under anaesthesia, thin stiff plastic tubes are inserted through the perineum (the area of skin behind the scrotum) and into the prostate. Radioactive wires are then inserted through the plastic tubes into the prostate, to implant radioactive seeds in the prostate.

Unseeded Prostate:

The image of a prostate before radioactive seeds are implanted.

Seeded Prostate:

The image of a prostate after the seeding procedure, where radioactive seeds are seen in the prostate gland. The radioactive seeds allow high dose radioactivity in the prostate to target cancer cells accurately while minimising damage to other body structures surrounding the prostate.


Advantages and Disadvantages of Radiotherapy

The option of radiotherapy as treatment for prostate cancer has the following advantages:

• It does not carry the risks of surgery, therefore it is useful in patients who cannot have surgery.
  


• It does not require long hospitalisation. Patients receiving external beam radiation does not even have to stay in the hospital - it is carried out as an outpatient procedure.
  


• Patients can return to normal life fairly soon, normally within a few days.
  

Disadvantages of radiotherapy:

• Tiredness, diarrhoea and cystitis (inflammation of the bladder causing a burning sensation when passing urine) are common short-term side effects.
  


• Damage to surrounding structures e.g. bladder, large bowel can sometimes occur, but this is uncommon as care is taken to minimise harm to structures other than the cancer cells.
  


• A small proportion of men (less than 5%) will have long-term bowel problems - bowel motions may become looser and more frequent. However, in most men these symptoms settle gradually.
  


• Patients receiving external beam therapy require frequent visits to the hospital radiotherapy unit as an outpatient for up to 6 weeks.

• There is a risk of impotence (inability to achieve and maintain an erection) and urinary incontinence (leakage of urine).
  

• The skin in the area where the treatment is targeted may become sore.

Source: Virtual Medicine

Making Decisions at Time of Diagnosis

The following article is excerpted from PSA Rising - Prostate Cancer Survivor (News, Info & Support) in the hope readers may become more informed. I would encourage all our readers to visit the author's website.

Slow down and take a breath before making any decisions about treatment. Prostate cancer can develop into a deadly disease. But for most men at time of diagnosis today, prostate cancer is not usually in need of immediate, emergency treatment. Most likely, you'll have time -- days, weeks and in some cases months -- to gather information and to decide among several treatment options.

Even so, a recent study found that men with stage T2 prostate cancer who had to wait nine weeks or more before receiving treatment by radiotherapy had a higher rate of recurrence unless they received a higher dose of radiation.

Your first task, with your doctors' help, is to get information about your Gleason grade and stage of prostate cancer and your PSA velocity.

Your second task is learn about which treatments offer you best outcomes in long-term survival and side effects.

Medical information about prostate cancer may be new to you. Your body is on the line, and new information may be hard to absorb. This may be the most complex decision you've ever made. Do what you can to make it easier on yourself.


A few practical steps will help you to get organized and on track:

* Bring someone with you to your appointments.

* Bring a notepad and tape recorder to the appointments.

* At home, set up a calendar, a phone number book and a file box (or file drawer) and a loose-leaf ring binder.

* Use the file for your new medical records, medical bills and health insurance papers, and for print-outs from reliable sources like medical journals.

* Use the binder to list your own questions and to jot down your doctors' replies. If you prefer to use a small notebook in the doctor's office, tape your notes into the binder when you get home.

* If you wish, jot down or clip and paste in info from sources like books, pamphlets and computer print outs. Family, friends and support group members may be able to help you gather and sift information.

* Select the most important points that may affect you. These are points you want to discuss with your doctors.

* Nothing is too dumb (or too clever) to ask.

* If you need privacy to talk to your doctor about impact of various treatments on sexual desire, lovemaking and erections, or bladder and bowel control, say so.

* Expect any doctor you would care to allow to treat you to be interested in your overall health and well being and to see you as an individual with cancer not as a statistic or person of a certain age.

* Don't underestimate the value of statistics and "cancer numerology." Graphs and studies tell a story about human beings.

*Seek a second opinion about your biopsy.

*Seek second opinions and, if needed, third opinions or more about your treatment options.

*If you're considering either surgery or radiotherapy (external beam or brachytherapy), find a practitioner who has done the procedure many times. Usually, this means going to a major hospital recognized as a national cancer center. Prostate cancer has no single best treatment. But evidence has shown that some practitioners are "artists" and quantity of experience also counts. Quality of equipment used (especially for external beam radiation) is key. Urologists (surgeons) and radiologists who are leaders in their field and who have treated the most patients do a better job.

* Take some time to consider the information you have been given before you make a final decision.

In many situations in life we don't make optimal choices, "we choose the first reasonable option, a strategy known as satisficing." Satisficing is OK if there's no big penalty for choosing wrong.

In life and death situations, many people do not carefully gather all available information and come to a rational decision. A study of fire commanders found that they "took the first reasonable plan that came to mind and did a quick mental test for problems. If they didn't find any, they had their plan of action."

Some of the best cancer doctors are trained to be able to "take the first reasonable plan," do the quick mental test for problems and, if none jump out, to sell that plan of action to the patient.

But these people already know most of the available information.

Reflection

After you've gathered and studied a full range of good information, it's fine to sleep on it and let the decision come naturally.

A Dutch study has found that people can think unconsciously and -- surprisingly -- that for complex decisions unconscious thought is actually superior.

Lead researcher Dr Ap Dijksterhuis told the BBC: "The take-home message is that when you have to make a decision, the first step should be to get all the information necessary for the decision.

"Once you have the information, you have to decide, and this is best done with conscious thought for simple decisions, but left to unconscious thought - to 'sleep on it' - when the decision is complex."

It's your body and your life. You want to stay healthy, productive and active for as long as you can. More than one type of treatment might work equally well for you. For some men, no immediate treatment may be the best decision. But don't lose sight of the fact that you probably have just one good chance of a cure. It's worth bucking the urge to "satisfice" too soon. Keep reading and asking questions. Do the best that you can to make the right choice for yourself. Don't sell yourself short. Then, when you wake up with the decision "made" by your gut, or your unconscious mind, you can accept that and go forward without looking back.

The following video may prove useful in trying to understand the range of options available for treating Prostate Cancer today.

Diagnosis and Treatment of Prostate Cancer