Howard Waage ---- Editor
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, April 27th, 2010 at 7:00 p.m.. For more information, please cal The Bennett and Suzy Katz Cancer Resource Center at Dominican Hospital (831) 462-7770
April 27th Meeting – Special Featured Speaker. Paid too much in taxes this year? The 2010 tax laws have changed so it might be good to plan ahead. Learn how to reduce your taxes and increase your income from Steve Okamoto, CLU, ChFC, 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 some unique planned giving techniques.You will not want to miss this one!
3/17/2010 - Active surveillance, also referred to as watchful waiting, is a viable option for many men with low risk prostate cancer, although the concept continues to cause distress and confusion. James L. Mohler, M.D., of Roswell Park Cancer Institute and chair of the NCCN Guidelines Panel for Prostate Cancer, discussed the role of active surveillance as well as other treatment options recommended in the recently updated NCCN Guidelines™ for Prostate Cancer at the NCCN 15th Annual Conference.
Dr. Mohler noted that in addition to various controversial aspects of management, other factors such as the complexity of the disease and the lack of sound data to support most recommendations only compounds the challenge of treating prostate cancer. “There are several variables that must be considered in order to tailor prostate cancer therapy to an individual patient and the NCCN Guidelines provide a solid framework on which to base these treatment discussions and subsequent decisions,” said Dr. Mohler.
Dr. Mohler discussed various organizations’ prostate cancer screening recommendations, including those recently updated by the American Cancer Society as well as the NCCN Guidelines for Early Detection of Prostate Cancer. “The current NCCN Guidelines recommend that at age 40, high-risk men begin annual PSA and DRE. All other men at age 40 should be offered a baseline PSA and DRE and if their PSA is 1.0 ng/mL or greater, they should receive annual follow-ups. If their PSA is less than 1.0, the NCCN Guidelines recommend that these men be early detected again at age 45,” said Dr. Mohler.
Dr. Mohler stressed that although PSA testing is a useful tool, it can be unreliable when used as a stand-alone measure. “Seventy percent of men with elevated PSA levels have negative biopsies and PSA can fluctuate up to 36 percent from day to day,” said Dr. Mohler. “I believe that the rate at which a PSA level increases, the PSA velocity or PSA doubling time, is a more accurate method of diagnosing prostate cancer.”
The use of PSA for early detection is most appropriate for men who are at increased risk for developing prostate cancer including those with a first-degree relative that had prostate cancer (a brother or father, especially when diagnosed before age 65) and African-American men, according to Dr. Mohler.
Dr. Mohler noted that the screening debate exploded in early 2009 as a result of the ERSPC (European) and the PLCO (American) studies published in the New England Journal of Medicine, resulting in media reports stating that PSA screening has little impact on the risk of death from the disease.
Dr. Mohler explained that these studies are important, but need to be considered in view of their flaws, including the lack of participant heterogeneity as only a very small number of trial participants had a family history of prostate cancer or were African-American. Also, in the European trial, the research protocols were inconsistent within the various study centers and in the American trial, the follow-up was too short and there was high contamination within the control group.
“The majority of men who participated in the two trials were not at a high-risk of developing advanced prostate cancer, so it is not surprising that PSA screening would have little impact on their risk of death from the disease,” said Dr. Mohler.
Switching gears from early detection to treatment, Dr. Mohler detailed significant additions to the updated NCCN Guidelines for Prostate Cancer, describing several related to active surveillance.
The NCCN Guidelines have established a new “very low risk” category that incorporates the strictest Epstein criteria from all definitions for clinically insignificant prostate cancer. In addition, active surveillance and only active surveillance is now the recommendation for many men diagnosed with prostate cancer. Men with low risk prostate cancer who have a life expectancy of less than 10 years and men with very low risk prostate cancer with a life expectancy of less than 20 years should be offered and recommended for active surveillance.
“We remain concerned about over-diagnosis and over-treatment of prostate cancer as growing evidence suggests that over-treatment of prostate cancer commits too many men to side effects that outweigh a very small risk of prostate cancer death,” stated Dr. Mohler. “The NCCN Guidelines Panel took careful consideration, including a thorough review of evolving data, of which men should be recommended for active surveillance.”
The active surveillance program recommended is defined in the NCCN Guidelines and stresses that active surveillance involves actively monitoring the course of the disease with the expectation to intervene if the cancer progresses. Dr. Mohler emphasized that patients under active surveillance must commit to a regular schedule of follow-up, which includes a prostate exam and PSA and may include repeat prostate needle biopsies.
“Ultimately this decision must be based on careful individualized weighting of a number of factors including life expectancy, disease characteristics, general health condition, potential side effects of treatment, and patient preference,” notes Dr. Mohler. “It is an option that needs to be thoroughly discussed with the patient and all of his physicians.”
Accurate life expectancy and time-to-death estimates are critical to guiding informed decision making in the treatment of prostate cancer. To calculate life expectancy, Dr. Mohler referenced the Principles of Life Expectancy Estimation in the NCCN Guidelines that recommend using the Social Security Administration tables and adjusting for overall health status and then comparing this to the estimated time to death from prostate cancer.
“Not all 65 year old’s are alike,” noted Dr. Mohler. “Calculating time-to-death from prostate cancer needs to incorporate a patient’s Gleason score, tumor volume, and tumor aggressiveness and that estimate needs to be compared carefully to a man’s physiological age, not his chronological age.”
As far as treatment modalities, two important updates were made concerning specific radiation treatment for prostate cancer to help prevent increased exposure and unnecessary side effects from radiation treatment.
The NCCN Guidelines now require daily image-guided radiation therapy (IGRT) for high-dose external radiation therapy. In addition, the NCCN Guidelines clarify what physicians should do when external beam radiation fails, recommending a more aggressive evaluation and recommending against salvage prostectomy, cryosurgery, or brachytherapy if the recurrence is not documented with a biopsy.
Pointing to recent headlines expressing concerns about radiation safeguards, Mohler stated, “The panel thought it was important that the guidelines address the increased side effects of high-dose external radiation therapy (XRT) when it is not given with rigorous quality controls,” stated Dr. Mohler.
The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 21 of the world’s leading cancer centers, is dedicated to improving the quality and effectiveness of care provided to patients with cancer.
Source: http://www.zerocancer.org/site/News2?page=NewsArticle&id=11449&news_iv_ctrl=1001
by Dr. Marc Siegel
3/11/2010 - As a primary care doctor who screens for prostate cancer every day, I can tell you that this disease is both common and potentially deadly. According to the National Cancer Institute, there were 192,280 new cases in 2009 and 27,360 deaths.
Screening for prostate cancer is helping to reduce the death rate. The European Screening Study is showing a 20 to 30 percent reduction in prostate cancer mortality due to screening. But deaths aren't the whole story. For every person who dies from prostate cancer, there are at least five who live in misery because of a late diagnosis.
Medicine is all about quality of life, and prostate cancer that has spread to the bones is painful and often resistant to treatment. Cure rate is a much more meaningful statistic to a doctor and his patient than death rate because patients who aren't cured must either live with symptoms, side effects of radiation or chemo, or the anxiety and fear that comes with watchful waiting.
This is why the American Cancer Society completely missed the boat when last month they suggested not screening a patient until the age of 50 and de-emphasized the use of the prostate-specific antigen test and the digital rectal exam.
I do my best to practice the art of medicine. Whereas the ACS now suggests that I spend 20 minutes discussing the advantages of prostate screening before I do it, instead I choose to have this discussion after I check a PSA and perform a digital rectal exam. This way, I can work with knowledge rather than guesswork. The idea of "not knowing" so that I don't treat too aggressively is an insult to serious doctors everywhere.
The decision of what to do if I uncover an abnormal PSA is complicated and also involves the art of medicine. A smart urologist will look at the PSA density (the result compared to the weight of the prostate) before deciding whether a biopsy is indicated. The heavier the prostate, the greater the PSA would be expected to be.
Along with the urologist, I also follow the PSA velocity, which is the trend, the rate that the PSA changes over time, rather than a simple number. Together we also look at the free PSA, a separate test which is much more indicative of prostate cancer than the PSA alone.
Deciding what to do with a prostate screening test is like shooting at a moving target, since the techniques for treating prostate cancer are always improving. "When you see a prostate cancer patient with a projected lifespan of at least 10 years, you need a definitive treatment," says Dr. David Samadi, chief of robotic prostate surgery at Mount Sinai Medical Center. Samadi performs more than 10 robotic prostate surgeries a week, using the latest technology, and claims a more than 90% cure rate with a restoration of sexual function in over 80% of patients.
At NYU Langone Medical Center, Dr. Herb Lepor, the chief of urology, a pioneer in the field of open prostate surgery, has operated on more than 3,000 cases and has also had great success with relatively few complications. But it is not the type of procedure that makes the biggest difference; it is the skill of the surgeon. Learning to tell the difference among surgeons is also part of the art of medicine.
The growing success of prostate cancer surgery with fewer and fewer side effects, coupled with the ability to diagnose the condition earlier, makes the PSA a crucial test. "Men who don't want to risk dying of prostate cancer should get screened," Lepor says. The younger the patient at the time of diagnosis, the more I, as a discerning internist, would like to offer him a disease-free future.
As a urologic oncologist, Samadi says he looks at the PSA as one of many important factors that contribute to the decision of whether to biopsy and possibly treat.
In contrast, PSA guidelines that restrict the use of the test undermine the thinking and judgment that goes into the real-life practice of medicine. What I do with PSA results depends on the patient's age, overall health, the skill of the surgeon (or radiation oncologist) at my disposal, as well as the patient's personal preference. I need to know the PSA in order to offer proper guidance, but the number alone doesn't guide me; my patient and I make that decision only after careful deliberation.
Marc Siegel, M.D. is an associate professor of medicine NYU Langone Medical Center. Source: http://www.zerocancer.org
==========================================================================================
Below are online resources for learning about your prostate cancer. "Prostate Cancer Websites" includes some of the more popular locations for newly diagnosed patients to do research, with links to more specialized sites where patients may go to get answers and do their “homework”. NOTE: The resources listed here are not a substitute for professional medical advice. Always consult qualified medical resources before making any treatment decision.
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.
Our support group has ongoing operating expenses beyond what our sponsors can provide. We do not have dues, but hope members will consider making any size donation to help us. Donations are welcome to assist us in maintaining and expanding our programs within the local community including the costs to run our website. The funds also help in keeping our library up to date with up to date books and literature regarding the treatment of prostate cancer, managing side affects, active surveillance, as well as information on nutrition, diet and lifestyle. Please make checks payable to "Santa Cruz County Prostate Cancer Support Group" and mail to:
Santa Cruz County Prostate Cancer Support Group
C/O Howard Waage
63 Asta Drive
La Selva Beach, CA 95076
---------------------------------------------------------------------------------------------------------
Fair Use Notice: This newsletter may contain copyrighted material whose use has not been specifically authorized by the copyright owners. We believe that this not-for-profit, educational use constitutes a fair use of the copyrighted material (as provided for in section 107 of the US Copyright Law). If you wish to use any copyrighted material for purposes of your own that go beyond fair use, you must obtain permission from the copyright owner.
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.