1. Unique and Valuable Services Provided
by Support Groups
– An information source that is completely free of
conflict of interest, an open marketplace for
information about all available treatment options
– An opportunity to meet others who have already
“been through the process”
– Venue for accessing information about local
doctors from men with first hand experience
2. Program Goals
1. Know all the treatment options that are available and
the side effects they can cause
2. Understand how to accurately place individuals into
the correct category or stage of prostate cancer
including a working knowledge of imaging and
pathology
3. Know the roles of the different medical specialists
4. Be familiar with basics of men’s health and commonly
used pharmaceuticals and supplements
5. Know the standards for screening & biopsy
3. Mentor’s Class Curriculum
1. Landscape I (Kirk) 7. Imaging (Margolis)
2. Landscape II (Scholz) 8. Low-Risk (Klotz)
3. Men’s Health (Moyad) 9. Intermediate (Scholz)
4. Side Effects (Mulhall) 10. High-Risk (Blasko)
5. Screen/Biopsy (Scholz) 11. PSA Relapse (Myers)
6. Medications (Moyad) 12. Advanced (Lam)
4. Privileged Role of Group Leaders
– Have the opportunity to share intimately in the
lives of others at their most challenging hour
– Are privileged to be an unbiased source providing
valuable information that will be potentially life
changing
5. Proper Character of Leaders
– Constantly developing in the humble skill of
imparting useful information to frightened and ill-
informed people
• Be sensitive to the fact that frightened people have
trouble concentrating and learning. Remember, “Fear
can’t hear.”
• Be sensitive to the fact that imparting knowledge
places you in a powerful position. Use the power
wisely by being gentle and patient
6. Burden of Support Group Leaders
• Valuable and accurate information may be
disregarded simply because you don’t have a
degree.
• The fact that information is provided without
cost may cause some to make the mistake of
valuing it accordingly.
• Conflicts of interest are so prevalent in this
arena that some people will still suspect you
have a hidden agenda.
7. Burden of Support Group Leaders
• Some people will mistakenly assume that your
reticence to make concrete recommendations
is due to your lack of knowledge
• Dealing with people who are convinced they
already know the answers will be much more
challenging than teaching beginners who are
still open to learning
8. The Risk of Being Ignorant, Reliance on a
Single Source of Information
– Under treatment
• Early mortality from improperly treated prostate
cancer
• Suffering the side effects of treatment for a cancer that
would not have relapsed if initial treatment was proper
– Over treatment
• Ignoring health issues unrelated to prostate cancer that
are likely to impair survival anyway
• Failing to balance the side effects of treatment with
their impact on quality of life
9. Providing Information with Perspective
– There are huge amounts of information on the
internet. However, information alone is useless
without perspective.
– Information about a treatment is only useful when
placed in perspective with:
• The individual’s
– Category of prostate cancer
– Age and health status
– Personal goals and quality of life priorities
• How each treatment compares with the other alternatives
– Comparisons are only possible by considering all the options
10. Categories of Prostate Cancer
– Newly diagnosed
• Low-Risk
• Intermediate-Risk
• High-Risk
– PSA Relapse
– Advanced disease
11. Newly Diagnosed
– Low-Risk
• Gleason < 7
• PSA < 10
• Small or absent nodule on digital rectal
– Intermediate-Risk
• Gleason 7 or PSA 10-20 or larger nodule on digital rectal
– High-Risk
• PSA > 20 or Gleason>7 or two or more Intermediate-Risk
factors or a nodule through capsule
12. 10-Year Survival by Risk Category
Low-Risk More than 100%
Brenner: Journal of Clinical Oncology 2005
Intermediate With treatment 98%
Mayo Clinic Journal of Urology 2008
High-Risk Surgery 95%
Mayo Clinic Journal of Urology 2008
13. “Gleason” Grading of Prostate Cancer
• Low grade (3)
• Higher Grade (4)
• Highest Grade (5)
• Score = “Adding Up”
two grades
15. Surgery
– Robotic
• Very dependent on operator quality like any prostate surgery
• When compared to the open approach;
– Cure rates equivalent to open technology
– Shorter hospital stays and quicker recovery
– Much smaller scars
– Equivalent risks of impotence and incontinence
– Open
• Certain famous practitioners contend that the open approach is
advantageous because they can “feel” the tumor and adjust
their margins accordingly.
• There is some evidence that positive margins are a little more
common with the robotic approach
16. Robotic Prostatectomy
Surgeon operates at the
console within a 3D view
Bedside surgical assistant
is next to the patient
Instruments move like a
human wrist (↑ dexterity
and precision)
18. Surgery
• Advantages
– More precise staging and estimates of relapse risk
compared to the other options
– Easier to do PSA monitoring to detect early relapse
• Disadvantages
– Higher risk of impotence and incontinence compared to
the other options (except cryotherapy)
– Higher risk of requiring further therapy such as
radiation and/or hormone (due to positive margins)
– Anesthesia risks such as heart attacks and short term
memory loss
19. Impotence Five Years after Surgery: 1288 Men
David Penson Journal of Urology 2005
• Incapable of an erection adequate for
intercourse even with Viagra
Age < 54 39%
55-59 51%
60-64 56%
> 65 82%
20. Incontinence Rates with the Best
Surgeon 12 mo
Pat Walsh (Open) 93%
Ahlering (Robotic) 94%
Shalhav (Robotic) 84%
Lee (Robotic) 90%
21. “Optimal Surgical Competency Requires a
minimum of 250 Practice Cases”
• In the New York during the whole of the year
in 2005:
– 25% of the urologists did a single radical
prostectomy
– 80% of the urologists did <10 cases
Savage & Vickers, Memorial Sloan Kettering
Journal of Urology December 2009
22. Intensity Modulated Radiation Therapy (IMRT)
– Advantages
• Substantially lower risk of impotence and incontinence
compared to surgery
• Cure rates at least as good as surgery and possibly better
– Disadvantages
• PSA monitoring after treatment is more ambiguous than
with surgery
• Small but real risk(1/50?) of a non-healing rectal burn
– Proton Therapy
• Same as IMRT in all regards except may possibly have a
slightly higher risk of non-healing rectal burn than IMRT
23. Active Surveillance
– Advantages
• Vastly lower risk of immediate side effects
– Disadvantages
• Prostate biopsy after a year. Every 2-3 years thereafter
• 5 alpha reductase inhibitors are occasionally employed
and may affect sex drive
• Cancer growing more rapidly than anticipated could
necessitate increased treatment (hormones plus
radiation instead of radiation alone?) than what would
have been necessary at initial time of diagnosis
24. Cryotherapy
– Total Cryotherapy
• Advantages
– Shorter treatment course than IMRT
• Disadvantages
– Highest incidence of impotence
– Incontinence rates comparable to surgery
– Focal Cryotherapy
– Still investigational
– Much lower rate of impotence and incontinence
– Only for carefully selected candidates
25. Hormone Therapy
– Advantages
• Reversible side effect
• Total body anti-cancer effect
• Enhanced surgery and radiation cure rates
– Disadvantages
• Side effects impact the whole body
• Controls, but rarely cures the disease
26. Brachytherapy
– Permanent Seeds
• Advantages
– Convenient outpatient administration
• Disadvantages
– Not appropriate for prostate size > 60cc
– Not appropriate for men with preexisting urinary issues
– Temporary Seeds
• Advantages
– Can cover outside the prostate in seminal vesicles
• Disadvantages
– Involves one or two hospitalizations for a couple days
30. HIFU
– Total HIFU
• Advantages
– Outpatient treatment given in a single procedure
• Disadvantages
– TURP required for treatment of larger glands
– Cure rates may be inferior to other options
– Only available outside the country
– Expensive
– Focal HIFU
– Still investigational
– Much lower rate of impotence and incontinence
– Only for carefully selected candidates
31. Treatment Selection Flow Chart
Active Surveillance
Low-Risk
Determine
Seeds or IMRT or Cryotherapy or
Disease Intermediate Surgery or Hormones or
Risk Active Surveillance or HIFU or
IMRT plus Short-Term Hormones
High-Risk
Long-Term Hormones plus
IMRT plus Brachytherapy
32. PSA Relapse
• Higher-Risk
– Newly-diagnosed risk category was high
– Early relapse (<2 years)
– Fast PSA doubling of less than 6-8 months
– Younger age
• Lower-Risk
– Newly-diagnosed risk category was low
– Delayed relapse more than 2 yrs after local treatment
– PSA doubling > 12 months
– Older age
33. PSA Relapsed Prostate Cancer
Cancer Type Life Expectancy after Relapse
• Pancreatic cancer 4 months
• Kidney cancer 6 months
• Stomach cancer 8 months
• Lung cancer 12 months
• Prostate cancer 160 months
35. Treatment Selection Flow Chart
1. Observation vs.
Lower Risk 2. Radiation to fossa vs.
3. Cryotherapy to prostate vs.
4. Intermittent Hormones
PSA Relapse
Radiation or Cryo to fossa plus
Higher Risk
Radiation to pelvic nodes plus
Hormone therapy (Plue
36. Advanced Disease
• Hormone resistance defined as a rising PSA
with testosterone less than 50 or
• A PSA over 100 or
• Proven metastatic cancer outside the lymph
nodes of the pelvis
37. Advanced Disease—Lower Risk
– Metastases but still hormone sensitive
– Lower PSA levels and slower rate of rise
– Relatively few bone metastases
– Disease limited to lymph nodes
– Not resistant to multiple treatments
– No detectable circulating tumor cells
38. Advanced Disease—Higher Risk
– Faster rate of PSA rise
– High levels of circulating tumor cells (CTC)
– More extensive bone metastases
– Bone pain
– Liver metastases
– Resistant to multiple treatments
40. Treatment Selection
• Any Risk
– Xgeva or Zometa monthly
• Lower Risk
– Hormonal treatment
– Provenge
– Combinations of both
• Higher Risk
– Chemotherapy
– Hormonal
– Combinations of both
41. Knowing When to Change Treatment
• After starting a new treatment monitor response
closely for 90 days by checking:
– PSA, PAP, LDH, ALP every 2-4 weeks
– Circulating Tumor Cells (CTC) monthly
– Bone scans CT, MRI and Pet scan every 3 to 6 months
– A reduction in pain is usually the first sign of a response
• Change treatment immediately if no response or if
excessive side effects
42. General Principles
• Be nimble by checking disease status frequently
and changing treatment right away when
something is not working
• All other things being equal, starting treatment
earlier is better than waiting
– Less cancer to kill
– Immune system is stronger
• Combination treatment is better than single
agents as long as the side effects or the cost are
not excessive
43. General Principles
• Physical fitness is totally critical
– Testosterone is low
– Age is advanced
– Almost all the treatments cause fatigue
• Prostate cancer kills by weakening bone marrow
– Use spot radiation and samarium sparingly
– Use Aranesp (to reverse anemia)
– Use Neulasta (to prevent infections while on chemo)
44. Conclusions #1
• Treatment selection is totally dependent on
being assigned to the correct category
– Newly-Diagnosed
• Low, Intermediate & High Risk
– PSA Relapse
• Lower vs. Higher Risk
– Advanced Disease
• Lower vs. Higher Risk
45. Additional Conclusions
• Unawareness of a treatment option is identical to
that treatment not existing
• Effective treatment administered early is superior
to the exact same treatment administered late.
So vigilant monitoring and detection of disease
progression early is critical.
• Physical fitness is important all stages but is
vitally important for men with advanced disease.
Notas del editor
New Developments for Relapsed Prostate Cancer April 1st 2003 Richard Lam M.D. Prostate Oncology Specialists, Marina del Rey, California
