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Both George and Pat have emphasised the importance of not losing hope – and I’m sure Henk wouldn’t argue with that, because what he is saying is that for the majority of men diagnosed with what is termed “prostate cancer” at present, there is never any need to lose hope because for the substantial majority of those men, the disease will never threaten them and will not result in any loss of life expectancy. Of course there are some men whose version of the disease will be very aggressive – it may not be possible to ‘cure’ those men, but it may be possible to manage the disease and curb it’s fatal advance for many years.
The issue is really how to define “cancer” and this was summed up by another doctor - Christopher Logothetis when he was talking to an US-TOO meeting in Texas. He had been commenting on the relative inaccuracy of the diagnostic process. The question put to him was:
"Does this mean that a lot of people who are diagnosed as having cancer really don't?”
His answer was:
"Yes, if one accepts the diagnosis that the cancer is a disease that is potentially lethal…….
One of the problems with prostate cancer is definition. They label it as a cancer, and they force us all to behave in a way that introduces us to a cascade of events that sends us to very morbid therapy. It's sort of like once that cancer label is put on there we are obligated to behave in a certain way, and its driven by physician beliefs and patient beliefs and frequently they don't have anything to do with reality.
And they are only worrisome because the pathologist has decided to call it a cancer.”
Another well known prostate cancer specialist was the late Dr Willet Whitmore (he is one of the personas after whom the current staging process is named) . Although he was very open minded about looking at better ways to treat the disease, he was among a number of his colleagues who disputed the value of the prostate-specific antigen, or PSA, screening test for men over 65. He recommended "watchful waiting" rather then rushing into surgery with older men with elevated PSA levels or even confirmed prostate cancers. In his view, survival had less to do with treatment than with the biology of individual tumors The paradox of prostate cancer was summed by him, succinctly as:
“Is cure necessary in those in whom it may be possible, and is cure possible in those in whom it is necessary?”
Apart from the issue of just how “cancer” should be defined, there is also the question of how “cure” should be defined. Currently, according to a recent study there are more than 200 definitions of cure, most of which refer to changes in PSA levels after treatment. But what most men are interested in is how long they will live – not necessarily their PSA levels, unless it can be shown that this is an accurate pointer to their potential survival. And of course there are simply no studies that demonstrate this with any degree of certainty.
There is a very large and long overdue study being undertaken in Europe to try and ascertain the value of current conventional treatments. It has not been running very long, but the initial reports after the first five years are coming out now. One of the interesting bits of information in one of the reports that in the initial reporting period 126 of the 1,014 men in this arm of the study died (12.4%), of these deaths 20 were prostate cancer related (2.0%), which is in line with national statistics that show prostate cancer related deaths to be about 3% of all male deaths.
Prostate cancer death occurred
• In four patients after surgery (two of perioperative complications),
• in ten after Radiation Therapy, and
• in six after ADT (Androgen Deprivation Therapy).
No patient initially managed with a Watchful Waiting policy died of prostate cancer.
Of course it is early days yet but there is a good deal of evidence around that Henk’s views are worth being considered by newly diagnosed men – or even with those who are told that their treatment has ‘failed’ merely because of a change in PSA levels.
I wouldn't dispute Henke's views on WW in the majority of men diagnosed with PSA. In my opinion, wherever it's possible, WW is the way to go.
Of course, in cases like mine and others where PSA is obviously soaring way beyond the norm and into the 100s or 1000s, we have no option other than deciding which treatment will be best for us.
I dearly wish all UK urolgists and oncologists would study the ideas of the doctors quoted above.
Day after day I see cases of men, many of them very young, having radical, sometimes damaging surgery purely because of a somewhat elavated PSA.
Just one point about PSA numbers. I for one am not too worried my levels if, and when, a rise occurs, they'll stay in double figures...(OK, I may be asking for trouble!) and I would most definitely take my time in decideing my next step...if I'm lucky enough to see just a gradual ascent.
Sudden surges over short periods of time, however, would definitely see me back on treatment.
Whichever way this wind blows me, I do WANT to live and will do all I can to survive.
Re: Re: There is no treatment for localized disease
Frankly, when I asked my doctor about watchful waiting he said and I quote, "You'd have to be out of your f'n mind". It all comes down to choices. No one sold me down the river. If the word Cancer does anything it starts you reading and learning your options. We're all adults and we all have made our beds. Mine was Robotic Prostatectomy especially since my father died of PC. Yours might be to wait but for how long?
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Replying to:
Thanks for such a detailed post Terry.
I wouldn't dispute Henke's views on WW in the majority of men diagnosed with PSA. In my opinion, wherever it's possible, WW is the way to go.
Of course, in cases like mine and others where PSA is obviously soaring way beyond the norm and into the 100s or 1000s, we have no option other than deciding which treatment will be best for us.
I dearly wish all UK urolgists and oncologists would study the ideas of the doctors quoted above.
Day after day I see cases of men, many of them very young, having radical, sometimes damaging surgery purely because of a somewhat elavated PSA.
Just one point about PSA numbers. I for one am not too worried my levels if, and when, a rise occurs, they'll stay in double figures...(OK, I may be asking for trouble!) and I would most definitely take my time in decideing my next step...if I'm lucky enough to see just a gradual ascent.
Sudden surges over short periods of time, however, would definitely see me back on treatment.
Whichever way this wind blows me, I do WANT to live and will do all I can to survive.
Henk
Do you think there is any value in giving high risk patients(grade 3) chemotherapy taxotere immediately after prostate removal, appartently there are several trials taken place at the moment to see if this cuts the risk of cancer returning.
Re: Re: There is no treatment for localized disease
Hello,
(site name for those who can read dutch)
I don't know the history, but it might help in high Gleason cases. However Taxotere is a pretty heavy deal when you are at the beginning of the road.
This can also work (see below). I have experience with one patient who became hormone refractory. He had nearly side effects on this regime and it postponed Taxotere for 2 years.
You could discuss this with your doctor
Best reagards,
Henk Scholten
Metronomic therapy with cyclophosphamide and dexamethasone for prostate
carcinoma.Glode LM, Barqawi A, Crighton F, Crawford ED, Kerbel R.
Oncology Urology Department, University of Colorado Health Sciences Center,
Denver, Colorado 80262, USA. mike.glode@uchsc.edu
BACKGROUND: The current study was designed to evaluate the efficacy and
toxicity of the continuous oral administration of a combination of
cyclophosphamide (50 mg/day given in the morning) and dexamethasone (1
mg/day given in the evening) in patients with prostate specific antigen
(PSA) progression despite single or multiagent hormone therapy and
antiandrogen withdrawal. METHODS: The authors retrospectively evaluated the
medical records of all patients with prostate carcinoma who were treated
with dexamethasone and cyclophosphamide and who were unable to participate
in Phase II drug trials or had failed previous chemotherapy regimens.
RESULTS: Using clinical response guidelines set forth by the Prostate
Specific Antigen Working Group, 29% of patients were found to have a > or =
80% reduction in PSA, 39% were found to have a 50-79% reduction in PSA, 6%
were found to have a < 50% decrease in PSA, and 26% experienced disease
progression while receiving treatment. The duration of response was 8 months
(95% confidence interval [95% CI], 4-10 months). The duration of treatment
was 9 months (95% CI, 6-14 months). The treatment was reported to be well
tolerated with side effects being primarily bruising, Cushingoid facies, and
gastrointestinal distress. CONCLUSIONS: In the current study, low-dose
dexamethasone and cyclophosphamide demonstrated efficacy as salvage therapy
in the treatment of patients with hormone-refractory prostate carcinoma.
Copyright 2003 American Cancer Society.
PMID: 14534880 [PubMed - indexed for MEDLINE]
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Replying to:
Henk
Do you think there is any value in giving high risk patients(grade 3) chemotherapy taxotere immediately after prostate removal, appartently there are several trials taken place at the moment to see if this cuts the risk of cancer returning.
The only caveate I would raise re: WW is to pay attention to the slope...the rate of increase...of PSA readings. My was pretty significant (3.4 to 8.8 in just over a year) so I opted to take action. My first reading after PBRT is 0.77.
But that is not the reason I am posting today. The following is from the electronic edition of the Gainesville (FL) Sun:
New hope for fighting cancer
By Diane Chun Sun staff writer
You might describe Dr. Jorge Galante as the ultimate educated medical consumer.
The 73-year-old orthopedic surgeon has been dealing with prostate cancer for a decade. After two years of conventional treatment, including surgery and radiation, his cancer recurred.
The Chicago resident went searching for an alternative to undergoing more of the same treatment.
His search brought him to a clinical trial involving immunotherapy now under way at Shands at the University of Florida, under the direction of Dr. Johannes Vieweg, professor and chairman of the department of urology.
Galante flies to Florida once a week to receive an injection of an experimental vaccine that enlists his body's own cells in the battle against cancer.
Every year, 230,000 men are diagnosed with prostate cancer. The American Cancer Society estimates that Florida will rank behind only California and Texas in the number of new cases diagnosed this year.
Vieweg brought his studies of the potential prostate cancer vaccine with him from Duke University when he joined the UF College of Medicine faculty in 2006.
He says the customized therapy overcomes many of the obstacles and side effects of other forms of cancer treatment because it uses the patient's own cells.
Blood is drawn from the patient and the dendritic cells are isolated from the white blood cells. They are then genetically manipulated to detect the antigens that mark tumor cells before being reinjected into the patient.
Antigens are protein fragments produced by invaders such as viruses or bacteria that trigger an attack by the immune system. Vieweg characterizes them as "a red flag" at the surface of tumor cells.
The antigen telomerase is overexpressed in prostate cancer and other human cancers, Vieweg explained.
Dendritic cells activate the immune system by capturing the antigen - in this case, telomerase - and presenting it to the body's killer cells, called T cells.
The custom-made vaccine is prepared in a $4 million "clean room" in the UF Cancer and Genetics Research Building. It's not a vaccine in the traditional sense. A patient can't get a shot or two and prevent cancer. But it does enlist the body's immune system to battle against cancerous cells.
"We have something unique here," Vieweg said.
Because the dendritic cells can be programmed to seek out tumor cells with pinpoint accuracy, they can combat cancer without causing further harm to the body, unlike radiation or chemotherapy.
The strategy being tested in the current clinical trial is not limited to prostate or kidney cancer, but is potentially applicable to all cancers, in Vieweg's view.
"We just haven't done the studies to determine which forms of cancer respond best to this therapy," the researcher said. "I'd have to say we're almost there."
"Almost there" is close enough for Galante.
As part of the clinical trial, Galante is helping to prove that the vaccine is safe and effective for use by others.
But for him, the immediate benefit is that he is able to lead a normal life.
"I have a wife, children and four grandchildren whom I want to see grow up," Galante said. "I have been waiting for this vaccine to come on line."
Diane Chun can be reached at 352-374-5041 or chund@gvillesun
