The Doctor is In: Prostate Health -- Sheldon Marks, MD -- 04/08/03

Last Editorial Review: 10/23/2003

By Sheldon Marks
WebMD Live Events Transcript

From benign enlargement to cancer, prostate problems will affect the majority of men at some point in their lives. We discussed the latest diagnostic tools and treatment options with Sheldon Marks, MD, author of Prostate and Cancer: A Family Guide to Diagnosis, Treatment and Survival.

The opinions expressed herein are the guest's 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.

Moderator: Hello Dr. Marks. Welcome to WebMD Live. Here's our first question.

Member: I'm a 46-year-old man. Because of a family history of prostate cancer, I had a PSA in February of this year, and it was 5.1, up from 3.2 two years ago. However, one month later a repeat PSA was down to 3.6. I asked the physician whether the conflicting results could have been due to the use of a different assay over the one used two years ago. He said yes, and that given the repeat results he was not worried. I'm scheduled for another PSA in May. Should I consult a urologist regardless of results?

Marks: Yes. Any time there's questions regarding prostate cancer and elevated PSA it's always a good thing to get a specialist's opinion. Because you're only 46 years old, a PSA of 3.5 is still of concern. Your ideal PSA should be less than 2.5. So you probably should still get a biopsy just to be sure.

Member: How does a physician determine whether a man has benign enlargement, prostate infection, or an overactive bladder?

Marks: Every patient that is seen has a basic urologic evaluation, which provides information to help the doctor separate out all of the different potential problems from each other. For example, an infection will usually be identified by bacteria and white blood cells in the urine. An overactive bladder is usually a symptom of some other problem, such as prostate enlargement, a bladder stone, bladder cancer, or even a stone in the ureter.

So when the urologist sees the patient he will do a complete examination, he will ask a series of maybe 20 to 30 questions, and with basic lab tests, including the urine and the PSA blood test, the doctor should know what is most likely the cause of your symptoms.

Member: I had radical prostate surgery on March 26 and tomorrow I have the stitches removed and more importantly the catheter removed. PSA was 4.1; Gleason was 6. What can I expect from here?

Marks: Most men will experience significant leaking simply because the bladder neck and urethra have been rebuilt and traumatized. To accelerate your recovery, you should be doing Kegel exercises all the time. You may even see some blood in your urine. The most important thing to do is to walk as frequently as you can to rebuild your strength and endurance. Most men will notice an improvement in their continence within a few weeks, often beginning during the night. The sooner you get back to your normal non-strenuous activities, the quicker your recovery.

Member: Doctor, I have a question about PSA. I am really confused about this. Some sources say this is an important test; others discount its value. What do you think?

Marks: PSA, which stands for prostate-specific antigen, is probably the most valuable test in finding cancer at an early stage in men and women. It is far more sensitive than a PAP smear or mammogram or any other test that is performed to look for cancer.

The problem is that many doctors don't understand that the test is prostate specific, not prostate cancer specific. Just because the PSA level is elevated, it does not mean that you have cancer. It means that something might be wrong and you should have further urologic evaluation. Because of the widespread use of the PSA blood test, the number of men dying of prostate cancer is decreasing significantly at a time when estimates suggest it should be going up.

Member: I'm currently 65 years old. I was diagnosed with prostate cancer in December of 1996 at the age of 58 and I underwent a radical prostatectomy the same month. I was told that the cancer had not spread to the lymph nodes that were biopsied during the surgery. I have been having routine PSA tests up until two years ago, and I was told that these were all within normal limits. Two weeks ago, I had a PSA as part of a routine medical exam. I was told that the result of the PSA was 0.17. My doctor said this should be undetectable. My question is why do I even have to have a PSA when I don't have a prostate; and, why do I have PSA that is detectable if I have not had a prostate for over six years?

Marks: Even after definitive treatment, such as removing the prostate, there is always a small chance that the cancer might return. Sometimes the cancer can lie dormant for many years before it starts to grow. Because of this, it is very important that you always have a PSA check for the rest of your life, whether you have had surgery or radiation or any therapy for prostate cancer.

When we detect a very low PSA, the first thing that I will do is repeat the blood test, as there is always a slight chance for lab error. If the blood test is indeed accurate, then it does suggest that there is a very tiny amount of prostate cancer somewhere in your body. The odds are great that this will not hurt you and simply requires that the PSA test be performed regularly to see if the level is increasing. The only time that we would consider treating this is if the PSA goes up rapidly or if the PSA reaches a critical value suggesting that there is a significant amount of cancer in your body. The vast majority of men that have a small recurrence do not die of prostate cancer.

Member: What are the symptoms of prostate cancer? I heard or read that hip pain could be an indication of prostate cancer.

Marks: There are absolutely no early warning signs or symptoms of prostate cancer. That is why it is essential for all men to have a prostate exam and blood test once a year. If a man has prostate cancer that has spread to the bones, which is still fairly rare, then he can have hip pain, back pain, rib, or shoulder pain. The odds are great, however, that the pain has nothing to do with prostate cancer, but still should be evaluated just to be sure.

Member: In Watchful Waiting, what does the "watchful" consist of? In other words, what are the general steps in monitoring?

Marks: Watchful Waiting is an excellent option for men who are diagnosed with prostate cancer when they are certain that they are going to die of something else before the cancer can hurt them. Watchful Waiting is best for very elderly and sick men who could not tolerate any of the treatments. This is not commonly selected. Many times we ask what are we waiting for, and the answer is we are waiting to find out if Watchful Waiting was the wrong choice, as evidenced by a rapid rise in PSA or symptoms of advanced disease. It should not be considered for young men or healthy men who are candidates for a curative option. Despite what many say, untreated prostate cancer still is a major killer of men in the prime of their life.

Member: Are you saying that with WW there is no way to monitor the condition and catch it before it is too late for RRP?

Marks: We watch prostate cancer grow by monitoring the PSA blood test. The PSA test is a helpful tool, but is not the definitive answer and can be misleading. The ideal time to have prostate surgery is when the cancer is still confined within the glands. This is often when the PSA is at its lowest levels, well below 10 and even below 4 in some men. Nobody knows for an individual when the cancer will start to grow through the capsule or spread to the lymph nodes. This is why Watchful Waiting, at this point in time, is still potentially dangerous.

Member: I had been diagnosed back in May 2002 and had originally decided on brachy but the prostate was too large. The radiation oncologist gave me a three-month Lupron shot. But even after three months, when the prostate reduced sufficiently, he recommended against brachy because of continuing frequent urination problems. Currently I am straddling the fence between WW and RRP.

Marks: Radical prostatectomy, when performed by an experienced and skilled surgeon, remains the most curative treatment available for prostate cancer. Naturally, because it is surgery, there are potential risks, but these risks are minimal when performed by a surgeon who knows what he or she is doing. The vast majority of men that choose surgery are very happy with their treatment.

If you are a candidate for surgery, then you should be limiting your options to treatments that will eliminate or kill the cancer so that you can get on with your life. If you choose Watchful Waiting, and the cancer continues to grow, which it will, you may lose that window of opportunity to do sometime curative. One point to know is that there is rarely any urgency to rush into surgery, but that doesn't mean that it is safe to postpone treatment indefinitely.

Member: My 26-year-old son, attending graduate school in China, was just diagnosed with a prostate stone. He was told not to worry, but to avoid alcohol, spicy food, and riding a bicycle, his only form of transportation. Does this sound reasonable to you? Or, should he seek another opinion?

Marks: Eighty-five percent of all males develop calcifications in their prostate. This is usually of minimal or no concern. If he has bladder problems then a urologist should evaluate him. If he has prostatitis, which is an infection of the prostate, then those recommendations are reasonable, but each person has to decide for himself what recommendations from his doctor he can and cannot follow.

It is fairly rare for a 26-year-old man to have problems with his prostate. My knee jerk response is to tell him to seek another opinion.

Member: Hello Dr. Marks. Thank you for being willing to spend some time helping to educate us. What do you suggest for someone who is, or soon may be, hormone refractory?

Marks: Hormone refractory cancer means prostate cancer that is no longer responsive to the removal of testosterone, whether from shots, pills, or surgical removal of the testicles. There are many new and exciting treatments available for refractory disease. These include chemotherapy, antifungal medications, and even vaccine. The new chemotherapy agents are showing very good results without the usual toxicity and side effects we often think of when talking about chemotherapy.

In my practice, when I have a patient who is not responding to hormone therapy, I refer them to a medical oncologist with special interest in prostate cancer.

Member: My father, age 60, was just diagnosed with stage T3a prostate cancer; his Gleason score is a 7 and psa of 17.8. The doctor also said he has "C disease." Can you explain this disease because I cannot find much info on it. Also, how high are these scores and what are some of his options?

Marks: T3 and C disease are two separate ways of describing the same stage of prostate cancer. This is when the cancer is fairly large and has probably started to grow through the wall of the prostate into surrounding tissues.

It is important to remember that each person is different, each cancer is different, and each person's cancer responds differently to each treatment. Depending on a man's age and health and longevity and personal preferences, a man with stage Ca may be a candidate for any of the standard treatment options. Most likely, though, one treatment alone will be inadequate and he may require sequential therapies, such as surgery to remove the majority of the cancer, followed by radiation or hormone therapy.

Member: If a doctor finds something questionable in the PSA blood test or exam, does the next step have to be a painful biopsy?

Marks: There are always options. Some you will like, some you won't. You oftentimes can choose to recheck the PSA in a few months. If, indeed, there are concerns, then a biopsy is important to have. For the majority of men, the biopsy is only momentarily uncomfortable. New techniques allow us to put anesthetic solution around the prostate before we do biopsies. With this I can almost always obtain 12 biopsies, ultrasound guided, without my patients complaining or letting me know that it hurts. Nobody is supposed to enjoy a biopsy, but considering how devastating and curable prostate cancer can be it is a small price to find out for sure that you do or do not have prostate cancer.

Member: Doctor, what is your opinion of the use of Celebrex as cytological inhibitor in treating possible recurrent prostate cancer?

Marks: Celebrex, like Vioxx, or Bextra, are all Cox-2 inhibitors, which are basically a very refined version of ibuprofen. Studies have shown that these products are actual anti-cancer substances and are being used during chemotherapy to improve results. Some studies have shown prevention of problems such as colon polyps, which can turn into cancer. If you tolerate the medicine, it can't hurt and can only help when used in addition to other therapies.

Member: The latest article in USToo stated thalidomide is used in cancer battle. Specifically, it is being tested for a possible cure for prostate cancer. What do you know about this? How close are we?

Marks: Thalidomide has been shown to have powerful anti-cancer benefits in men with advanced hormone-resistant prostate cancer. It is still considered investigational and should be taken as part of a research study so that we can learn how much help it really offers to men. Reports are very positive about thalidomide at this point.

Moderator: Dr. Marks, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Marks: First, it's essential that people be proactive in their health and that they use their knowledge, spread the word to so many others that are afraid to find out if they have cancer, and to remember that if you have prostate cancer in the family, that all males are at increased risk and need to be seen starting at age 40.

Second, I would encourage everybody to eat a heart-healthy diet, high in fruits and vegetables, and very low in red meat and dairy, as study after study shows that a healthy diet can prevent prostate cancer and reduce its aggressiveness and improve your immune system so that you can better deal with prostate cancer or any other problems that may develop. So do like your mother said, and eat your vegetables.

Moderator: Our thanks to Sheldon Marks, MD, for joining us today. For more information, please read Prostate and Cancer: A Family Guide to Diagnosis, Treatment, and Survival by Sheldon Marks, MD.

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