Prostate Cancer Treatment Update (cont.)

Other options exist and because there's no single standard of care, this decision is best made by consultation with a multidisciplinary group of physicians, including a urologist, a radiation oncologist and if available, a medical oncologist.

Is surgery still an option if cancer reoccurs after seed implants or radiation therapy?

Surgery after seeds or external radiation is associated with a higher risk of complications than if it is performed prior to such treatment. It is the subject of a clinical trial that is ongoing nationally.

In most circumstances patients whose cancers were not cured by seed implants or external radiation would not be good candidates for surgery. But, individual circumstances differ and options need to be considered in light of the higher risk of complications.

I have prostate cancer (PC). When it was first diagnosed the biopsy showed one of eight samples had cancer. I am 81 years old. My cancer is T2 and my Gleason score is 3+3=6. I elected to go on "watchful waiting" and hope to outlive the cancer. I go to my doctor two times a year for checkups. Do you think this is a wise choice for me or should I be more aggressive with treatment? I had transurethral resection of the prostate (TURP) right after diagnosis and none of the tissue had any cancer.

Watchful waiting is considered a reasonable option for patients with lower grade smaller volume cancers. In particular, it's a reasonable option for older patients for whom a slow-growing cancer may not be a potential risk to their lives. Of course, we do not know the optimal patient at this time that does not need any treatment for their cancer. That is why watchful waiting is only one of a list of choices in this type of circumstance.

Your age plus the Gleason score and low volume of cancer would make you a particularly attractive candidate for a watchful-waiting program, since it may take many years, as many as 15 to 20, for such a cancer to be clinically a risk to you. That said, cancers may change over time, so close follow-up on a watchful-waiting program, including frequent examinations of the prostate, PSA testing and occasional rebiopsies of the prostate are likely to allow you to know if this cancer is changing.

"There is no data currently about whether any treatments given after surgery can definitively prevent recurrence, with the exception of external radiation to the prostate bed."

Two years ago I had my prostate removed and I have had my PSA tested every four months. My last PSA was 0.04 (less than the required 0.1) How often should I have my PSA tested and what should I do to stop the cancer from returning?

I think that continuing PSA checks every three to six months in this situation is reasonable. A PSA of 0.04 is still very low after surgery and consistent with cure. However, only time will prove this and if, in fact, the PSA were to continue to rise, then that would be a sign that microscopic residual disease is present.

There is no data currently about whether any treatments given after surgery can definitively prevent recurrence, with the exception of external radiation to the prostate bed. This would be a consideration if your PSA were to continue to rise and if scans did not demonstrate evidence of cancer outside of the prostate bed. Beyond this additional radiation treatment, there still remains very little data about whether treatments such as hormonal therapy, nutritional interventions or other treatments can prevent recurrence.

In your situation I would continue to follow as you are and consider options depending on how fast the PSA is rising, if at all.

My dad had PC, so it may run in the family. I am now 41 years old. What steps should I take to help me avoid prostate cancer?

Prostate cancer does tend to run in families. The recommendation of the American Cancer Society and the American Urological Association for men such as you, who have a first-degree relative with prostate cancer, is to have a screening PSA test and prostate examination in their early 40s. Since you are now 41, it would be a reasonable issue for you to discuss this with your primary physician.

Regarding prevention of prostate cancer -- little is known about whether any specific nutritional or drug intervention would decrease your chances of getting prostate cancer. However, epidemiological studies have suggested that certain nutritional interventions for instance, might decrease the general risk of getting prostate cancer. These include a low-fat diet, particularly animal fat, moderate exercise, increased uses of tomato-based products which have an antioxidant called licopene in them and decreased use of dairy products, although this remains controversial. Vitamin E and selenium are also possibly associated with a decreased risk of prostate cancer. However this is a subject of a prevention trial currently ongoing in the United States.

There was another prevention study looking at the drug Proscar published several years ago in the New England Journal of Medicine. This study suggested that men who took this drug had a decreased risk (25%) of prostate cancer after seven years. However, the type of cancers that developed during the study period appeared to be of higher Gleason score, namely more aggressive in appearance. This has led many experts to hold off on the recommendation to routinely take a drug such as Proscar for cancer prevention.

In summary, most of the data here would suggest that some dietary and nutritional interventions might decrease the overall risk of prostate cancer but this has not been clearly proven. A PSA test would be a reasonable thing to consider over the next few years for you.

"Generally, with each passing year, and at 5 and 10 years, a person who has no evidence of recurrence measured after surgery, such as a PSA that's undetectable, should be increasingly confident he's been cured."

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