Monthly Meeting

Where: Our meeting will be in the Bennett & Suzy Katz Cancer Resource Center on the 1st Floor of the two-story redwood Education Building behind Santa Cruz Dominican Hospital.

When: Tuesday, March 30th, 2010 at 7:00 p.m. For more information, please call The Bennett and Suzy Katz Cancer Resource Center at Dominican Hospital, (831) 462-7770.

March 30th Meeting – Special Featured Speaker Daniel Lewis, Ph.D. was diagnosed with prostate cancer in November 2007. In January 2008 he and his prostate were separated due to irreconcilable differences. Janice, the prostate, wanted to metastasize. Daniel wanted to live. Daniel, a Research Scientist and resident of Monterey will present parts of his as yet unpublished manuscript “The Gland at the Center of the Universe,” a humorous and melodrama-free account of his encounter with prostate cancer from symptom to diagnosis to treatment and recovery. Daniel’s motto: If you don’t laugh, you’ll cry…. You will not want to miss this one!

UPCOMING EVENT--- April Meeting – Special Featured Speaker

Have you paid too much in taxes this year? Learn how to reduce your taxes and increase your income from Steve Okamoto, a prostate cancer survivor and director of planned giving for the American Cancer Society. Steve will give you some hints on how to reduce your tax bill for next year by using unique planned giving techniques and other tax saving advice for the new year.

Prostate Cancer in the News

Similar Effectiveness Among Options for Managing Low-Risk Prostate Cancer

ScienceDaily (Jan. 11, 2010) — A comprehensive appraisal of the management and treatment options for low-risk prostate cancer found that the rates of survival and tumor recurrence are similar among the most common treatment approaches, although costs can vary considerably. The report was prepared by the Institute for Clinical and Economic Review (ICER), a leader in comparative effectiveness research based at the Massachusetts General Hospital's Institute for Technology Assessment.

Bringing together the findings from three previous reviews completed by ICER, the final summary report, "Management Options for Low-Risk Prostate Cancer: A Report on Comparative Effectiveness and Value," compares multiple approaches to managing the most common non-skin cancer among U.S. men:

• Active surveillance, with careful monitoring and referral for surgery or radiation if necessary;
• Radical prostatectomy, surgical removal of the prostate via traditional "open" or robot-assisted approaches;
• Brachytherapy, implantation of radioactive seeds in the prostate;
• Intensity-modulated radiation therapy (IMRT) and proton therapy, two forms of external radiation therapy.

The ICER review found that there are no definitive head-to-head studies comparing these options, but that accumulated evidence from multiple studies over the years suggests that overall survival and the rate of cancer recurrence are quite similar among all options, including active surveillance. There are different risks for certain side effects and complications, but no treatment option stands out as superior overall. Because low-risk prostate cancer is typically slow-growing and may not cause any symptoms, active surveillance is a reasonable option, particularly for men 65 and older, approximately half of whom will never have their cancer progress to the point of requiring treatment.

"ICER's review provides a welcome objective summary of what we know and what we don't know that can help men in conversations with their doctor," stated David Most, PhD, prostate cancer survivor and Founder and President of Health Information Research, Inc., who was a member of the Evidence Review Group that participated in the ICER appraisal process. "Given the numerous sources of information we have on the different management options, it really can be difficult to know what to do. Having a report like this from ICER will help patients make informed healthcare decisions that reflect their values about the risks and benefits among the different options."

The ICER report included a review of published literature on the treatment of low-risk prostate cancer as well as simulation modeling to project the long-term effects of each treatment approach. The evidence on radical prostatectomy, brachytherapy, and IMRT was judged to demonstrate comparable overall clinical effectiveness for most men, while there was not enough evidence to date to make a comparison on proton therapy. The evidence on active surveillance was stronger for older men, and therefore ICER rated its clinical effectiveness as comparable to immediate treatment for men 65 and over. Long-term outcomes with active surveillance are not yet available, but for younger men active surveillance may still be a reasonable option given that surgery or radiation can be done if regular blood tests and prostate biopsies suggest the cancer is growing. The ICER report also found that, based on Medicare payments, active surveillance costs approximately $300-$1,000 per year, while brachytherapy and radical prostatectomy procedures cost approximately $10,000. IMRT and proton therapy are more expensive, costing $20,000 and $35,000 per treatment course, respectively.

"ICER works hard to create unbiased, fully-informed appraisals of disease management and treatment options so that patients, clinicians, and payers can trust the information produced," stated Steven D. Pearson, MD, MSc, FRCP, President of ICER. "The results of the summary report on low-risk prostate cancer are an example of how scientifically-sound comparative effectiveness research can be presented in an actionable way for multiple audiences. Ultimately, this type of research can help improve patient outcomes and overall value in the healthcare system. " Source: http://www.sciencedaily.com/releases/2010/01/100105112113.htm

 

AN UPDATE OF THE GLEASON GRADING SYSTEM

PURPOSE: An update is provided of the Gleason grading system, which has evolved significantly since its initial description.

MATERIALS AND METHODS: A search was performed using the MED-LINE(R) database and referenced lists of relevant studies to obtain articles concerning changes to the Gleason grading system.

RESULTS: Since the introduction of the Gleason grading system more than 40 years ago many aspects of prostate cancer have changed, including prostate specific antigen testing, transrectal ultrasound guided prostate needle biopsy with greater sampling, immuno-histochemistry for basal cells that changed the classification of prostate cancer and new prostate cancer variants. The system was updated at a 2005 consensus conference of international experts in urological pathology, under the auspices of the International Society of Urological Pathology. Gleason score 2-4 should rarely if ever be diagnosed on needle biopsy, certain patterns (i.e. poorly formed glands) originally considered Gleason pattern 3 are now considered Gleason pattern 4 and all cribriform cancer should be graded pattern 4. The grading of variants and subtypes of acinar adenocarcinoma of the prostate, including cancer with vacuoles, foamy gland carcinoma, ductal adenocarcinoma, pseudohyperplastic carcinoma and small cell carcinoma have also been modified. Other recent issues include reporting secondary patterns of lower and higher grades when present to a limited extent, and commenting on tertiary grade patterns which differ depending on whether the specimen is from needle biopsy or radical prostatectomy. Whereas there is little debate on the definition of tertiary pattern on needle biopsy, this issue is controversial in radical prostatectomy specimens. Although tertiary Gleason patterns are typically added to pathology reports, they are routinely omitted in practice since there is no simple way to incorporate them in predictive nomograms/tables, research studies and patient counseling. Thus, a modified radical prostatectomy Gleason scoring system was recently proposed to incorporate tertiary Gleason patterns in an intuitive fashion. For needle biopsy with different cores showing different grades, the current recommendation is to report the grades of each core separately, whereby the highest grade tumor is selected as the grade of the entire case to determine treatment, regardless of the percent involvement. After the 2005 consensus conference several studies confirmed the superiority of the modified Gleason system as well as its impact on urological practice.

CONCLUSIONS: It is remarkable that nearly 40 years after its inception the Gleason grading system remains one of the most powerful prognostic factors for prostate cancer. This system has remained timely because of gradual adaptations by urological pathologists to accommodate the changing practice of medicine. Source: J Urol. 2010 Feb;183(2):433-40. Epub 2009 Dec 14

There Is Too Much Valuable Information In The Pathology

I am an ex-pathologist and was at one time highly skilled in the pathology of lymphomas. I was the youngest charter member of the Society of Hematopathology formed back in the 60's. I have relatively little skills in the pathology of prostate cancer. Yet I recall looking at the slides of a patient the night before his scheduled RP (he consulted me the day before) and told him to postpone his RP because I could not identify anything on the slides that looked remotely like prostate cancer. The slides were reviewed by an expert and concurred that no prostate cancer was to be seen. That patient came back to visit me every year to celebrate his not having prostate cancer.

The point I am trying to make is when the course you travel is highly dependent on the accuracy of your compass, you better make sure that your compass is accurate. Until we have accreditation involving special skills (pathology of PC, RP, cryo, etc), I routinely have asked for a second opinion with an ACKNOWLEDGED expert in this field. I do not go by the reputation of the medical center or the university. It is the person with the skill not the building. I jokingly, but seriously, say that those who put their life in the hands of a building have an "edifice complex". So, for the 300th time I will paste in my blurb about pathology:

Despite the fact that the Gleason score might NOT change after an expert review, the reality is that more often it does. However, the issue is who did the first review. There are talented pathologists who are focused on prostate cancer and also two national labs who are focused on prostate cancer as well.

The Gleason score is a critical item; it is used as a variable in virtually every prognostic and treatment algorithm. An accurate GS mandates an expert pathology opinion from a PC pathology expert. The ones that I am most familiar with include:

• Helmut Bonkhoff (Berlin, Germany); Tel: +49-30-8331802 or +49-30-8330441; bonkhoff@prostapath.de
• David Bostwick (Virginia) 800-214-6628
• Ronald J. Cohen (Western Australia) 61-8-9386-9888; ronnie@uropath.com.au
• Jon Epstein (Hopkins) 410-955-5043 or 410-955-2162 (Dr. Epstein does not do ploidy analysis)
• David Grignon (Michigan) 313-745-2520
• Scott Lucia 303-724-3470
• Jon Oppenheimer (Tennessee) 888-868-7522

Note that it is these individuals who you want the second opinion to come from and not someone that works in the same department or in the same organization.

A second opinion on the microscopic pathology is usually covered by insurance but if not, runs about $500 depending on what is done. A copy of the original pathology report with the actual slides or recuts from the tissue blocks are sent to the outside reviewer. My preference is to request that tissue blocks be sent to the expert reviewer to optimize the recuting process. Your primary care doctor or you can initiate such a 2nd opinion but you need to request this and ask for a specific physician or lab to be used.

Additionally, other prognostic tests such can be extremely helpful to plan therapy. These tests are done using IHC (immunohistochemistry) and include: AMACR, AZGP1, AR, BCL-2, CGA, COX-2, EGF-R, FAS, HER2/Neu, HSP-27, MIB-1, MUC-1, PAP, PSA, p27, p53, Somatostatin, D2-40. Ploidy analysis can also be done by some of the above pathologists using the tissue blocks. There are extra fees for these services. For me, the most detailed and comprehensive pathology review is done by Helmut Bonkhoff in Berlin, Germany. Also, I know when pathology material is sent to him that he reviews the material and not an unknown associate using his name.

Material posted here is intended for educational purposes only, and must not be considered a substitute for informed medical advice from your own physician.

This information was provided by Stephen Strum, MD written on the Physician to Patient mailing list. The P2P is a moderated internet mailing list which permits patients to asked focused, clinical questions about prostate cancer. Timely responses are provided by physicians expert in the treatment of prostate cancer. All ideas should be shared with your medical doctor. Stephen B. Strum, MD, FACP Medical Oncologist specializing in prostate cancer since 1983.

Subscription to the Physician to Patient mailing list and it’s archived questions found at: http://prostatepointers.org

Participating in Clinical Trials - The Ins and Outs of Enrolling in Clinical Trials

Clearly, no new therapy for prostate cancer will ever make it into your doctor’s hands if people don’t enroll in clinical trials. There would be no way to prove whether the therapy is safe, whether it is effective, and whether it can help improve the lives of men with prostate cancer. Should you be one of the men who enroll in a clinical trial? What are the potential upsides? And what are the potential downsides?

In general, the best time for you to consider enrolling in a clinical trial is when you know that your prostate cancer is progressing, but you feel well and the best treatment option available for you remains controversial. For example, suppose your PSA is rising after initial therapy but you have no other signs of advanced disease and you’re feeling well. This might be the perfect time to enroll in a clinical trial because the researchers will be able to tell fairly easily whether the drug is affecting your disease progression and how the drug will affect you. The researchers would watch whether your PSA continues to rise or starts to fall, and how long it takes you to develop detectable metastases. The combination of these factors would give them insight into how well the drug is working and whether it might be useful in other men at this stage of disease. Of course, enrolling in such a clinical trial might also allow you to try a new treatment to which you might otherwise never have access, a therapy that might slow your disease and offer some benefit.

Regardless of the specific objectives of the trial, there is much knowledge to gain from every person who enters the trial. Although the researchers conducting the trial will learn a lot more if you stay in the trial for a longer period of time so they can monitor your progression over time, they’ll often be able to gather some helpful information from your case even if you get out after only a short time, so you should never feel like you wasted your time and their time if you can’t make it all the way through. On the other hand, if you know in advance that you’re unlikely to be able to stick with the regimen for one reason or another, discuss with your doctor whether there might be a different trial that’s more suited to you. Also, keep in mind that clinical trials are used to evaluate new treatment regimens at all stages of disease, so if you aren’t up to joining a trial at one point, that doesn’t mean you’ve lost your chance.

Source: http://www.prostatecancerfoundation.org *(Excellent website for information on all aspects of prostate cancer)

Free Lending Library For Prostate Cancer Information

The Santa Cruz County Prostate Cancer Support Group maintains quite a few up to date books and videos about prostate cancer, prevention, diagnosis and treatment options for anyone interested in doing research or needs information about this disease. The library is located at the Katz Cancer Resource Center Dominican Hospital Education Building 1555 Soquel Drive, Santa Cruz, CA Open 9 a.m. to 4 p.m. Monday through Thursday 10 a.m. to 2 p.m. Friday or by Appointment (831) 462 7770.

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The Santa Cruz County Prostate Cancer Support Group does not endorse any provider, organization, product or individual.  All medical decisions should be made with the advice and consultation of medical professionals.

Many THANKS to the American Cancer Society for assisting with the printing and mailing of this newsletter and the Katz Cancer Resource Center for allowing us to use their facility.