WebMD Live Events Transcript

The statistics say most men will have prostate problems at some point. In recognition of Men's Health Week, we explored a number of prostate concerns, and looked at prevention, diagnosis, and treatments with E. Roy Berger, MD, FACP, a founding member of the Prostate Cancer Education Council, on June 15, 2004.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MEMBER QUESTION:
My prostate surgery was 14 months ago. So far there is not a trace of cancer retuning. At that time (before surgery), I was taking testosterone injections every two weeks. Since surgery, I have no erections at all. Would it now be safe to take testosterone injections again? I have tried Viagra, etc., with no help at all. What can you tell me?

BERGER:
I would say current information tells us to stay away from any and all testosterone injections at this time, because if there are prostate cancer cells in your body, it may be like throwing gasoline on a fire and causing them to grow.

MEMBER QUESTION:
I am 64+; have had an elevated PSA for last seven years, generally between 6 and 9.7. For the last two years, numbers have stayed on the higher side. I've had four biopsies -- all came back OK. Should I consider another biopsy where they take 30 to 40 samples versus the usual seven to eight? Any other thoughts?

BERGER:
I would suggest getting a free total PSA ratio. If the ratio is 25% or above, the chances are that the process is benign, especially since you have had so many negative biopsies. If any of the biopsies showed prostatitis and you have not had a one-month course of an antibiotic, such as Cipro, I would recommend that, followed by another PSA test.

There is a new test available on prostate tissue that predicts if there is prostate cancer in an otherwise benign specimen, but I'm not sure if it is yet commercially available.

I would continue to follow PSA values on an every three- to four-month interval and do the saturation biopsies if there is anything suspicious on digital rectal exam or if the PSA rises, or if the PSA ratio is significantly less than 25%.

MEMBER QUESTION:
How old should you be when you start to get a prostate exam?

BERGER:
Current recommendations for screening for prostate cancer are age 50 and above for digital rectal exam and PSA annually, unless you have a family history of prostate cancer or are an African-American, in which case a PSA and DRE (digital rectal exam) should be done annually beginning at age 40 to 45.

MEMBER QUESTION:
Are there any signs to watch out for between exams to tell if something might not be right?

BERGER:
The signs of prostate cancer are usually due to advanced disease and are very difficult to tell from benign disease. These signs are:

Difficulty urinating
Frequency of urination
Pain during urination
Blood in the ejaculate
Bone pain

MEMBER QUESTION:
I am a 64-year-old male and had seed implantation for prostate cancer in November 2003. Starting in December 2003 I have had a problem that whenever I pass urine it burns a lot. I am taking Flomax. I have had the burning sensation (sometimes strong) for six months now. Is this normal?

BERGER:
It is normal and usually goes away between four and six months; however, in some people it takes longer. Sometimes anti-inflammatory medications, such as Celebrex, Vioxx, and Advil will help decrease the symptoms.

"The signs of prostate cancer are usually due to advanced disease and are very difficult to tell from benign disease."

MEMBER QUESTION:
My dad and two of his brothers had prostate cancer. What are my chances of getting it? And can I do something to help myself not get it?

BERGER:
Your chances of getting prostate cancer are, unfortunately, two to three times of that of the normal population, which is about one in six to nine. So your chances are three times that, probably 1 in 3 or 4.

You should have your PSA checked and DRE done annually at the age of 40. Make a strong consideration of a low-fat diet that is high in vegetables, especially like broccoli and Brussels sprouts. Other additives that have been shown to help avoid prostate cancer are vitamin E, 400 milligrams daily, selenium, 200 micrograms daily, and licopene between 10 and 30 milligrams daily.

Recently the results of the prostate cancer prevention trial have been published, showing that the addition of a five alpha-reductase inhibitor (PROSCAR in this trial) have been shown to reduce the incidence of prostate cancer by approximately 25%. There was, however, a small increase in the number of high-grade cancers compared with the control group (not taking PROSCAR).

At the recent American Society of Clinical Oncology meeting in New Orleans, Cox-2 inhibitors (Vioxx, Celebrex, Bextra) appeared to decrease the incidence of PC (prostate cancer).

There is an entire chapter in my book, Updated Guidelines for Surviving Prostate Cancer , covering diet and other modalities to help inhibit the growth of prostate cancer and prevent it.

MEMBER QUESTION:
Is there going to be true hope for systemic PCa patients in the near future, meaning are there going to be effective drugs against systemic PCa, apart from docetaxel and, perhaps, satraplatin?

BERGER:
There is some excitement in the field of immunology in that there is a vaccine called Provenge that in the first phase-III trial showed an approximately 8.5-month improvement in medial survival over patients who were on the placebo. This vaccine is a dendritic cell vaccine that stimulates the patient's T cells to find and attack prostate cancer cells.

The final registration trial prior to possible FDA approval is currently ongoing. There are about 60 sites throughout the U.S. that are involved in this trial. Currently, patients who have hormone refractory metastic prostate cancer that is measurable by scans, whose Gleason score is 7 or less, and who have no pain, are candidates for the trial. For information as to the nearest site geographically, please call 1(866) 788-3949.

I am a principal investigator in this trial on Long Island. There is an entire chapter explaining more about it in our book.

MEMBER QUESTION:
How good and safe are the new cryogenic methods?

BERGER:
In the hands of an experienced cryosurgeon at the seven-year mark it appears to be as effective as any of the other primary therapies for prostate cancer; however, longer-term data is not available. It can be helpful in patients who have failed radiation or radioactive seed implantation. Again, the procedure is very technically operator dependent. I would only put myself in the hands of an experienced cryosurgeon.

"In general, PSAs above 4 are abnormal; however, this does not mean that you have prostate cancer, and there are a number of ways to proceed."

MEMBER QUESTION:
Is there a way to test my prostate by myself?

BERGER:
No.

MEMBER QUESTION:
Is it standard practice to have an EXTERNAL photo of one's more "sensitive areas" taken and then displayed in their medical records glossy side up, knees spread wide apart, posterior in a most unflattering position, everything private being exposed to all? My doctor asked if I'd like to see the photos of my colonoscopy; I nearly had a heart attack when I saw what was displayed and how. Now I will not go back for another exam. That is worse than mere embarrassment.

BERGER:
An external photo, unless there is some pathology that needs to be illustrated, is usually not done.

MEMBER QUESTION:
My PSA is now at 32. Have had everything done except chemo. Does it help or is it more misery than it is worth?

BERGER:
I assume that you have prostate cancer and have been treated with multiple hormonal manipulations. The chemotherapy that has recently been shown to improve survival, i.e., Taxotere and Taxotere combined with Emcyt, can be given in a relatively nontoxic way. Although the overall survival gain has been reported at approximately three months, we have had a number of patients live much longer without undue toxicity.

The decision to take chemotherapy or not is a very individual one that needs to be discussed with your medical oncologist. There are other treatments, such as the Provenge vaccine that you might be a candidate for.

MEMBER QUESTION:
I have been recently diagnosed with PCa. The grade was 7. I inquired if staging was in order and was informed it was not necessary, and that I had three options: surgery; radiation; seeding implants. Should I undergo the staging process prior to surgery? I am concerned. Is surgery ever performed without the staging process? If so why or why not? Any help you can provide would be greatly appreciated.

BERGER:
This is a lengthily answered question and is dependent upon several variables, which include your PSA level, whether or not your Gleason score was 4.3 or 3.4, both of which are 7, and how many cores and what percentage of each core were positive for cancer.

Staging, unfortunately, has been notoriously inaccurate; however, we do CAT scans, bone scans, and endorectal coil MRIs for patients who we consider high risk. Again, there is a lot more data about risk and staging, including Partin tables and risk nomograms in the book.

MEMBER QUESTION:
My hubby had his prostate removed 10 years ago due to cancer. He is 61 years old. It came back two years later, and he had radiation. Now it is back again. He is now taking hormones. How long can he take these? His last PSA test showed the hormones brought the PSA back down. Is there a better treatment? How come removing the prostate and lymph glands didn't get it all?

BERGER:
Like any other cancer, any primary therapy for prostate cancer, including radical prostatectomy, unfortunately does not cure everyone. Most likely cancer cells escaped and went to other areas of the body prior to his surgery, and salvage radiation did not kill them all.

Currently, hormonal therapy is the mainstay of treatment for your husband's prostate cancer. There are a number of different ways to treat patients like him with hormones. Intermittent therapy is one. We are currently doing clinical trials to see its efficacy compared with continuous hormonal therapy (which has more side effects). Again, for greater in-depth information, see the chapter on intermittent androgen blockade in my book.

MEMBER QUESTION:
What is the normal protocol after having a PSA test result of 4.95?

"Staging, unfortunately, has been notoriously inaccurate; however, we do CAT scans, bone scans, and endorectal coil MRIs for patients who we consider high risk."

BERGER:
There is no normal protocol. It depends upon the age of the patient, the size of the gland, and the digital rectal exam results. It also depends on the rate of rise from previous PSAs. In general, PSAs above 4 are abnormal; however, this does not mean that you have prostate cancer, and there are a number of ways to proceed. Your urologist should best be consulted.

MEMBER QUESTION:
I have had a radical prostatectomy in October of 2000. PSA started rising going to 0.2 and went on hormones for three months. I then underwent radiation for six weeks once a day. PSA dropped to 0.0 and stayed there until February 2003 to 0.2. It has been climbing >.05 every three months. It is now 1.0. They want to put me back on hormones, but I would like a second opinion. What would you think would be the best approach?

BERGER:
It sounds like there are still prostate cancer cells in your body. A workup, including CAT scans, bone scan, and a prosta-scint scan may be able to detect where these cells are.

It sounds as if hormonal therapy will be needed at some point. Most of the data to date indicate that earlier, rather than later, hormonal therapy would be helpful. Again, there are a number of different ways hormonal therapy can be administered, and I believe that combination hormonal therapy is more efficacious than single-drug treatment. Updated Guidelines reviews the various types of hormonal therapies and their advantages and disadvantages. The decision of which of these to go on would be based upon your overall health and discussions with your physicians.

MODERATOR:
Dr. Berger, we are almost out of time. Do you have any final words of wisdom for us?

BERGER:
I know I have mentioned my book on a number of occasions. The reason for it being that I spent two years writing it with my co-author, who is a prostate cancer patient himself. We believe that we have addressed, in a very comprehensive way, most of the questions that can be asked about this disease. The best way to get it (especially if you are a prostate cancer patient) is to go to the Education Center for Prostate Cancer Patients, web site: www.ecpcp.org, or call (516) 942-5000.

Thanks for your interest in this chat, and I hope I have helped some of you.

MODERATOR:
Thanks to E. Roy Berger, MD, FACP, for sharing his expertise with us. For more information, please read his book, Updated Guidelines for Surviving Prostate Cancer .

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