 |
 | Home | Contact Us | FAQ | Search & Site Map | Link to Us |
 | Sign In | Join | Other 45 Sites in Network |
Medical Forum / Diseases and Disorders / Prostate Cancer / June 2005Questions regarding recurrance - What the hell?
I received Dr Catalona Quest Newsletter: An article written by Jules Reichel of the URF board writes: http://www.drcatalona.com/quest/Spring05/quest_spring05_6.asp Recurrence over the 10 years after treatment was much too frequent. On average: For Low-risk patients: normally PSA= 10ng/ml or less, and Gleason Score= 6 or less, there was 20% recurrence. Medium-risk patients: normally PSA between 10 and 20ng/ml, or Gleason Score = 7, there was 50% recurrence. High-risk patients: normally PSA greater than 20ng/ml, or Gleason Score 8-10, there was 66% recurrence. and For the Gleason Score 5-7 patients, the probability of metastasis varied between 16 and 25% at 7 years; and for the Gleason Score 8-10 patients, the probability of metastasis varied between 43% and 93% at 7 years after recurrence. I was ALWAYS under the impression that the odds of recurrance for PCa was low. After reading this article I'm lead to believe that is NOT the case. Jules goes on and writes about the "New Era" PSA testing: Earlier screening beginning at age 40 (or 35 in some cases); A PSA screening threshold of 2.5ng/ml with the potential of early biopsy using 12 or more cores; Emphasis on improved diagnostic techniques especially including the use of PSA velocity and doubling time to guide the necessity for and the type of treatment; Emphasis on viewing surgery and follow-up high dosage radiation therapy (usually IMRT at dosage levels over 70Gy), when required, as a compatible pair of processes rather than only as opposing options; Non-invasive treatment of patients with cancer-precursor high grade PIN disease, when appropriate. Many men at age 50 have PIN. The presence of "high grade" PIN (HGPIN) implies later cancer in almost half of men. (This work is in-progress). Prostate cancer RUNS IN MY FAMILY. How the hell am I suppose to prevent it from killing me if I get it? Looking at the odds that Jules writes, even with a Gleason 6, I still have a 1 in 5 shot of dying from it! And if I have the more common Gleason 7, Jules writes 50%...Someone please help me understand. I was under the impression that if caught early esp with a low gleason and PSA, the chances were suppose to be like 98% of NO recurance. hi dick - i was going to put this post in the psa thread, but you specifically was asking about recurrence of pca. this one paragraph really bothered me, but he explains a lot about the psa concern. first, the parapraph, then the entire article. ~ curtis =================a successful radical prostatectomy should result in an undetectable PSA level. Actually, nothing is ever that simple. It is possible to leave benign glands at the bladder neck during prostatectomy. This can result in a low level of PSA production. Also, tiny quantities of PSA are made in some accessory glands along the urethra. ========Prostate Specific Antigen (PSA) What is PSA? PSA is a protein manufactured in the prostate and virtually no other organ. Women, who lack prostates, do not have detectable levels of PSA. Actually, PSA is the enzyme responsible for liquifaction of semen a few minutes after it has clotted. The prostate glands manufacture this protein in large quantities. If you look at this photomicrograph you can see a single normal prostate gland tubule cut in cross section. The cells lining the center, or lumen, manufacture prostate secretions including PSA. There is also a circle around the cells, called the basement membrane, which stops PSA and other secretions from entering the blood stream. All of your glands, your intestines, and your urinary tract are organized the same way: a secreting or absorbing layer of cells with a basement membrane to keep a tight separation between the inside and the outside. That is how the prostate makes a lot of PSA but only a tiny amount normally is found in the blood. What causes abnormal PSA levels? You need to understand that the prostate gland cells (the epithelium) are manufacturing PSA. The cells will continue to manufacture PSA if they are in locations outside the prostate. PSA levels in the blood go up if the barrier between the epithelium and the bloodstream is damaged. Three typical sources for damage are: cancer, bacterial infection, and prostate infarction or destruction of part of the prostate by damage to its blood supply. Minor elevation of the PSA levels is sometimes due to cancer, but normally a little PSA leaks from the prostate into the blood. If the prostate is enlarged then the leakage appears exaggerated. This is probably why the PSA can be slightly abnormal in men with enlarged prostates who do not have cancer. Trauma to the prostate, as by physicians performing prostate massage, and sex can also cause minor transient elevations of PSA. The PSA level in the blood can vary by about 20% from day to day. Nevertheless, the data are clear that a single abnormal PSA value puts one in the higher group for prostate cancer. Now that we know the test can be falsely elevated by trauma, infections, and intercourse, we inquire after these factors before accepting the validity of the blood test. How does PSA assist cancer treatment? Before getting into the complicated business of how we use PSA in cancer detection I want to make clear its use in monitoring cancer treatment. Since only prostate cells make PSA, a successful radical prostatectomy should result in an undetectable PSA level. Actually, nothing is ever that simple. It is possible to leave benign glands at the bladder neck during prostatectomy. This can result in a low level of PSA production. Also, tiny quantities of PSA are made in some accessory glands along the urethra. Naturally, PSA is a wonderful marker for the success of prostate cancer surgery. If we remove a patient's prostate and all of the cancer was inside, then the PSA should go to very low levels. If some cancer cells had escaped from the prostate, then the PSA will remain measurable or become measurable and continue to rise after a few years. As a practical matter, PSA readings over 0.5 usually indicate residual or recurrent cancer following radiation or surgery How do we use PSA for diagnosis of prostate cancer? To us, the data are clear that prostate cancer screening is beneficial. Patients who are at risk for prostate cancer include men over age 50. The sons and brothers of prostate cancer patients should start screening earlier as their risk of prostate cancer is at least double the general population. We have recommended age 40 for a first PSA for these men. African Americans also have a higher risk of prostate cancer. Unhappily, the national rate of participation of African Americans in screening programs is poor. PSA is reported in terms of nanograms of protein per milliliter of serum (ng/ml). The scale is open-ended. Men with advanced and widespread prostate cancer can have PSA readings over 2,000 ng/ml. The assay is performed using labelled antibodies on a serum sample. The test is run most days. You do not have to fast for this blood test. The general rule is that PSA is normal from 0 to 4.0. If the level is between 4.0 and 10.0 then about 35% of men have prostate cancer. If the level is between 10.0 and 20.0 then about 65% of men will be found to have prostate cancer. Levels above 20, in the absence of infection, are usually associated with more advanced prostate cancer. We use a PSA of 20 as our cutoff for prostate biopsy in very old men who do not have symptoms. If the PSA is over 20 we worry that they will turn up one day with prostate cancer that has spread to their spine. To prevent this, we want to make the diagnosis and start treatment . As always, the situation is a little more involved than I've implied. First off, men around 50 years old with small prostates should have PSA readings below 2.4. Conversely, men in their seventies with large prostates are probably normal up to a PSA of 5.6. Finally, if the physical examination is suspicious for prostate cancer we proceed with biopsy even if the PSA is normal. Men with a suspicious digital rectal exam and a normal PSA should undergo biopsy only in the suspicious area. Men with an elevated PSA undergo biopsies throughout their prostate gland. This disciplined approach to biopsy allowed us to demonstrate that even a little cancer in the biopsy specimen meant that the patient had a significant prostate cancer. We recommend prostate ultrasound and biopsy for early diagnosis in men who are candidates for definitive treatment if we discover prostate cancer. This means that in men of advanced age and those with major heart or lung diseases we recommend biopsy only when we see a high risk of rapidly progressive cancer. What is the role of free PSA? Scientists and physicians have been trying to make the PSA test even more useful for several years. Most of these attempts (PSA density, PSA velocity, age dependent PSA ranges) were impossible to verify and were not very useful. Free PSA, however, is both reproducible and useful. Free PSA is that percentage of the total PSA which circulates in the blood without a carrier protein. The graph on the right, provided by Dianon, Inc., bears careful study. The horizontal axis is the percentage of free PSA. The two graphs come from analysis of 4,000 patients with abnormal total PSA between 4 and 10 ng/ml. The red line, corresponding to prostate cancer patients, has a sharp peak at 10%. Most patients with prostate cancer have a free PSA less than 15%. The blue line corresponds to the distribution of free PSA in patients whose biopsies did not show prostate cancer. AUC means "area under the curve". The relative size of the area under the curves for prostate cancer and benign prostate enlargement correspond to the chances of finding prostate cancer. The point here is that patients with PSA below 7% usually have prostate cancer. They should undergo biopsy. If biopsy is negative they need repeat biopsy at frequent intervals if the free PSA is reproducibly low. Patients with free PSA over 25% usually have benign prostate hyperplasia. These patients should, in our opinion, undergo a single ultrasound and biopsy session. As a single session is about 85% accurate in finding prostate cancer these patients have a residual risk after biopsy of less than 3%. Therefore, they need their blood rechecked annually but do not require repeat biopsy evaluation unless the free PSA starts to fall or the total PSA continues to rise, which would imply interval development of a cancer. Total PSA Range 2.5 to 4.0 ng/ml Age Range (Years) %Free PSA<60 (yrs)>` (yrs)All Ages<78495917-1525494316-25102722>25276 Total PSA Range 4.01 to 10.0 ng/ml Age Range (Years) %Free PSA<60 (yrs)>` (yrs)All Ages<78795937-1527504816-25122727>25377 Total PSA Range10.01 to 20.0 ng/ml Age Range (Years) %Free PSA<60 (yrs)>` (yrs)All Ages<79397977-1543716716-25224745>2551515 Free PSA may eventually allow us to forego biopsy altogether in men with PSA between 4 and 10 and a free PSA of >24%. Below are the tables from Dianon regarding cutoff ranges for PSA II and prostate cancer risk. We think that these tables allow physicians and patients to make reasonable decisions as to the need for prostate biopsy. There is no clear right or wrong answer as to when biopsy should be undertaken. In our practice, we prefer to err toward more biopsies in patients with a life expectancy over 20 years. We tend to look for reasons not to biopsy men with a life expectancy right around 10 years. In men with truly abbreviated life expectancies, we perform prostate biopsy only when there is a suggestion of aggressive rapidly growing cancer. knowledge is power - growing old is mandatory - growing wise is optional "Many more men die with prostate cancer than of it. Growing old is invariably fatal. Prostate cancer is only sometimes so." http://community.webtv.net/PALMER_ENT/doc Curtis, I'm assuming that paragraph could pertain to a small rise in PSA without the cancer returning? >From my reading it seems that for men under 50 anything over .7, one needs to watch more careful, perhaps this is where the PSAV plays an important role. http://www.drcatalona.com/quest/Winter04/quest_winter04_1.asp "Q: What do you recommend for prostate cancer screening? A: I recommend an annual PSA and digital rectal examination beginning at age 40, or earlier in men with a family history of early age-at-onset prostate cancer. A PSA level of 0.6 to 0.7 or less in men 40 to 50 years old is evidence of a healthy prostate gland." Curtis, I'm assuming that paragraph could pertain to a small rise in PSA without the cancer returning? =========== this is the problem that shows up with an elevated psa after the RP. the reason the psa level shows up is because there are some prostate cells left behind. are they the good ones, BPH cells, or PCa cells. only time will tell and that is one hell of a waiting game. i've already got my first taste of it and didn't like it. ~ curtis knowledge is power - growing old is mandatory - growing wise is optional "Many more men die with prostate cancer than of it. Growing old is invariably fatal. Prostate cancer is only sometimes so." http://community.webtv.net/PALMER_ENT/doc Another one up at the wee hours of the morning. Can't you guys sleep?? Well Dick, you certainly awoke me from a comfortable state of ignorant bliss. I had no idea that I still had such a high chance of reoccurrence after ten years. Guess I will keep those life insurance policies paid up after all. Come to think of it, the uro was strangely silent on this subject when giving me the path report. All I heard was organ contained disease and clear surgical margins and thought I was out of the woods. Better start eating more tomatoes (lycopene, is that the good stuff?). On you family history, just keep on top of the PSA's and stay well educated on the subject so you are ahead of the game if you face making a treatment decision in the future. I had a friend whose father died of PCa and my buddy did not even know his PSA (age 55+). Scary. He was tested at my prompting, and no problem. Lucky for him...so far. Good luck to you. Thank you for this information. I am glad to know this even though it did scare me a bit. David S. > I received Dr Catalona Quest Newsletter: An article written by Jules > Reichel of the URF board writes: [quoted text clipped - 50 lines] > with a low gleason and PSA, the chances were suppose to be like 98% of > NO recurance. David, didn't mean to startle you. I just seem to be reading conflicting articles. Acutally Dr Catalona does recommend Lycopene. "After reviewing the data of this report, I only recommend Vitamin E in doses of 80 milligrams or less, except for patients at risk for severe macular degeneration. I still recommend a low saturated fat, low red meat, high vegetable diet with daily selenium 200 micrograms, lycopene 30 milligrams and an inexpensive multivitamin." http://www.drcatalona.com/quest/Spring05/quest_spring05_8.asp I did notice he made no reference to the tocopherols in vitamin E. > I received Dr Catalona Quest Newsletter: An article written by Jules > Reichel of the URF board writes: [quoted text clipped - 23 lines] > was low. After reading this article I'm lead to believe that is NOT the > case. Go back and read the article again. The point is to distinguish between results before PSA screening and early detection were common from what seems true with such methods in force. The listed figures were from the "old, bad days". The point of early detection is to catch prostate cancer before it metastasizes. The high recurrence rates from the pre-PSA era are an indication that many cases were not caught before metastasis occurred. Later in the article he gives figures on likelihood of recurrence under today's conditions, which are much lower. Critics of PSA testing would respond that a recurrence rate of 20 percent for Gleason 6 cases is not that bad, and that with PSA testing many more men whose cancers would never have bothered them are being treated. I guess it depends on your perspective: whether you are more worried about the side effects of treatment or the disease. Gleason 7 cases, by the way, are much less common than Gleason 6 cases, which consitute the vast majority of prostate cancers that are treated these days. > Jules goes on and writes about the "New Era" PSA testing: > [quoted text clipped - 22 lines] > with a low gleason and PSA, the chances were suppose to be like 98% of > NO recurance. I get the Quest newsletter also and if I weren't ALREADY peeing in my pants (although it's getting better...I hope :-), my initial reaction was to START. Then, as Len pointed out, I re-read the piece and realized that it WAS about the time when PSA wasn't used as a predictor the way that it is now. Still, after having a good path report with no lymph node or seminal vesicle involvement and free margins, I was surprised that Dr. Catalona never said anything to me about "cure" or "we got it all", etc. He said that it was good news and the 5 week post-op PSA was undetectable which was ALSO good news. I had meant to ask him (but didn't)...how it could come back? I think that Curtis pointed out a bit of that. I can STILL call the doc but will wait a bit. He wants a PSA in 6 months and a DRE in a year. I HAVE thought about recurrence but as David S. said...with negative results and confined tumor...hopefully things will be good. I'm glad that this topic was brought up as upon reading the said 'Quest' article...I was reaching for the phone. Good Health, Ron B. Chicago > I get the Quest newsletter also and if I weren't ALREADY peeing in my > pants (although it's getting better...I hope :-), my initial reaction [quoted text clipped - 12 lines] > > I had meant to ask him (but didn't)...how it could come back? The question is whether or not the cancer was in fact totally confined to the prostate. If that was the case, then your surgery cured you without a doubt. If some cancer took up residence outside the prostate before your surgery, then there are two possibilities. First, it could be just be extension from the prostate, and in that case, it would be confined to the local area and it would be possible to cure it with radiation. Second, cancer with metastatic capability might have taken up residence at remote sites. In that case, the surgery couldn't cure you. The best it could do is to reduce the amount of cancer in your body, but the remote cancer would likely develop at some later date. In that case, you would need hormone therapy which could control the cancer for some period of time. In a case like yours, the likelihood that the cancer was entirely contained in the prostate and you are now cured is very high. But it isn't 100 percent. There is still a remote possibility that it will recur. As time goes on, if your PSA stays undetectable, the likelihood of it every recurring gets even smaller. So in a sense you approach a cured state but you never actually get there. > I think that Curtis pointed out a bit of that. > [quoted text clipped - 13 lines] > > Chicago Leonard, I have gone back and re-read it, but fail to see where Jules Reichel states the statistics were from pre-PSA. In fact Reichel writes "The Rate of recurrence in the PSA-Era was too high". He then goes on to mention a "New PSA era". Essentially a lower cut off point with the inclusion of fPSA and PSAV. HOWEVER Reichel article uses a higher PSA cut offs points. For Gleason 6, he uses PSA 10 or less. 10-20 for Gleason 7 and over 20 for Gleason above 8. I'm not sure what distinction that has from using a standard PSA 4 for all gleason scores. It's actually a fairly confusing article since he's not using the standard PSA 4.0 cut off point that's been applied for over 10 years. Reichel states "Recurrence over the 10 years after treatment was much too frequent. On average: --For Low-risk patients: normally PSA= 10ng/ml or less, and Gleason Score= 6 or less, there was 20% recurrence. --Medium-risk patients: normally PSA between 10 and 20ng/ml, or Gleason Score = 7, there was 50% recurrence. --High-risk patients: normally PSA greater than 20ng/ml, or Gleason Score 8-10, there was 66% recurrence." Does anyone know if the Partin tables correspond to Reichel's 10 year "findings"? Plus in the Winter edition of Quest, Dr Catalona states "Fortunately, now, most cancers we find are organ confined, and treatment by a skilled doctor provides a good chance of no recurrence in a large majority of patients." http://www.drcatalona.com/quest/Winter04/quest_winter04_1.asp I'm going to Email Jules Reichel - He needs better clarification in this article. Does Dr Catalona approve all articles before they are published? If I get PCa in my 40's or 50's, I want a better shot than 50/50 of being around in 10 years if it's the path report says 3+4 or higher!! > Leonard, > I have gone back and re-read it, but fail to see where Jules Reichel > states the statistics were from pre-PSA. In fact Reichel writes "The > Rate of recurrence in the PSA-Era was too high". right after that, the recurrence figures we have been discussing are listed. The look further down after "The New_Era offers something better". > He then goes on to > mention a "New PSA era". Essentially a lower cut off point with the [quoted text clipped - 4 lines] > above 8. I'm not sure what distinction that has from using a standard > PSA 4 for all gleason scores. PSA 4.0 was the cut-off point previously used for deciding whether or not to do a biopsy. Due to recent research by Dr. Catalona and others, that seems to be reduced to 2.5, particularly for men in their 50s. The PSA 10 number refers to something different. Generally, the higher the PSA before treatment, the greater the likelihood of metastasis. PSA m10 seems to be a natural division point with men who have PSA less than 10 having a significantly better prognosis than men with PSA greater than 10. But, of course, not all the PSA > 10 have recurrence and some of the PSA < 10 men don't avoid recurrence. > It's actually a fairly confusing article > since he's not using the standard PSA 4.0 cut off point that's been [quoted text clipped - 14 lines] > Does anyone know if the Partin tables correspond to Reichel's 10 year > "findings"? The Partin tables only indirectly have anything to do with estimates of recurrence. The Partin tables only tell the likelihood of the pathologist seeing various things when he examines the tissue that was removed in radical prostatectomay. For example, for a Gleason 7=3+4 T1c cancer with PSA less than 10, the likelihood of seminal vesicle or lymph node invovlement is only about 5 percent or so. But the pathologist can't examine your entire body under a microscope so he can't eliminate the possibility that some cancer cells exist elsewhere in your body. If cancer gets to the lymph nodes, that makes it more likely that you have the beginnings of metastatic cancer, but even in that case, it is not certain. > Plus in the Winter edition of Quest, Dr Catalona states "Fortunately, > now, most cancers we find are organ confined, and treatment by a [quoted text clipped - 9 lines] > If I get PCa in my 40's or 50's, I want a better shot than 50/50 of > being around in 10 years if it's the path report says 3+4 or higher!! Under current practice, with a Gleason 7=3+4 cancer, your chances of being around in 10 years are much, much higher than 50 percent. I'm familiar with those statistics since I had exactly such a cancer. > ... It's actually a fairly confusing article > since he's not using the standard PSA 4.0 cut off point that's been > applied for over 10 years. ... The PSA numbers cited in the article refer to cutoff points for different "risk" levels of disease. < 4.0 was thought to mean that a man didn't have cancer - though current thinking is that 4.0 is too high to conclude that. <10.0 and Gleason < 7 mean "low-risk" cancer. This cancer is not as likely to kill you, or to kill you as quickly, as the higher risk cancers. Between 10 and 20, or Gleason 7 meant "intermediate risk" >20 or Gleason >=8 meant "high-risk" cancer. Alan |
Reply to this Message |
 Sign In
 Join
 My Latest Posts My Monitored Threads My Blog My Photo Gallery My Profile My Homepage Start New Thread Enable EMail Alerts Rate this Thread
|
©2008 Advenet LLC Privacy Policy - Terms of Use
This website includes both content owned or controlled by Advenet as well as content owned or controlled by third parties.