Prostate Health (cont.)

I'm 68 years old and have had two heart attacks. I'm not sure about undergoing surgery. What do you think about watchful waiting?

Watchful waiting is a reasonable treatment for prostate cancer only if the odds are great you're going to die of something else before the cancer can hurt you. So, even though this writer has had two heart attacks, the question is -- what's his longevity? Some men with heart attacks are walking on thin ice and may not survive very long. Other men have a heart attack and 30 years later are still viable, healthy, happy people. So the specifics of the heart attack need to be addressed with the cardiologist.

The great news is that all these other treatments like the IMRT, radioactive seeds or cryotherapy provide very good treatments with very little risk.

The problem with watchful waiting is that if a man has a significant cancer and does nothing, the cancer will continue to grow. If it grows and becomes a problem, usually it's much harder to treat later on than it would have been early on. So we primarily reserve watchful waiting for small volumes of low-grade cancer in elderly men who are likely to die of something else normally, or in men who have such significant health problems that any of the treatments are a threat to them. So, for the majority of men, we're not too happy with watchful waiting.

Now, the question comes up -- how long can we go with watchful waiting? And the answer is probably if it's a low-grade small cancer, you might be able to go years. Studies have show that you can go out 10, 14 years. The problem is, the majority of men, if they live long enough, will still die of prostate cancer. It may be 14 to 17 years later, but these cancers are still growing and they still, no matter how small or benign they are early on, they move in the wrong direction. They become larger and more aggressive.

So he should talk to his urologist and his cardiologist and ideally have the two doctors talk to determine what treatments are reasonable, if any, and in what time frame.

How does Casodex affect the liver? My husband was on hormone therapy for four months due to a PSA of 0.4 after prostatectomy and after the hormone therapy his ALT (alanine aminotransferase) liver function was elevated at 70. Should we be concerned?

The Casodex is an antiandrogen and what it does is it changes the cancer cell's ability to identify and use the male hormone testosterone to make the changes that stimulate cancers to grow. So it's kind of like putting blinders on the cancer cells. The testosterone is still there. The cancer cell just doesn't see it.

As with all medications, from aspirin all the way up to the most dangerous medicines, there's always potential for side effects. With antiandrogens, one of the risks is that it can injure the liver cells.

A particular level of 70 for some men may be of minimal concern; for others it could be significant. So it's important that the doctors who placed him on the Casodex have monitored the liver function tests over a period of time and discussed this with the primary care physician, and if necessary, a liver specialist, to see if this particular test is at a level of concern and if it's moving in a direction that's not favorable. If it's been 70 on three separate checks, he is doing well with it and the doctors are comfortable watching, then that's totally fine. If it was 28 and then 45 and now at 70 and there's concern -- there are other antiandrogens and other hormonal treatment options that can be used instead of the Casodex.

My husband has been off Lupron and Casodex since May 15 but is still experiencing hot flashes. How long will this continue?

To understand how long it will continue, we need to take a moment and look at how these treatments work. Lupron, Zoladex and Eligard -- all of these medicines are designed to drop the testosterone levels down as if the man had been castrated. It's a chemical castration.

The advantage to these injections is that it's reversible in the majority. What we know, from research, is that the testosterone does not come back immediately upon completion of the medicine. In fact, men who have been on these medicines for years, oftentimes it can take years for the testosterone to return. So the fact that he just stopped it a short time ago, I'm not surprised he is still having hot flashes, which is a common side effect when the testosterone level is low. It may take months or it may be even years before the hot flashes go away. The good news is as the testosterone levels return slowly, the hot flashes will also start to dissipate.

It's important for him to not only monitor his PSA levels to make sure the cancer isn't coming back, but also to be monitoring the testosterone levels because that can be a warning sign. If the testosterone comes back and jumps up rapidly and the PSA follows, then we know that he needs to go back on some hormone therapy.

What is the life expectancy of someone in the fourth stage of prostate cancer?

Well, it's very hard to say because there are so many factors that enter into determining potential life span. I do know that I have had patients that almost 20 years ago had very aggressive prostate cancers and are still alive today. Some of those men still have cancer but it's not significant in their life span. I know of other men that had very small volumes of low-grade cancer and died of that cancer within six months.

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