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What could be the reason for increase in Prostate-specific antigen levels?

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My dad is 74, and in great health, but his PSA total numbers continue to spike from October til now; it is now a PSA Total of 26. His %free psa continues to rise, and this is quite confusing. I am wondering if this BPH (he has no symptoms of this) or God forbid, some type of agressive cancer? His digital did not detect any nodules, and he is scheduled for a sonogram/biopsy. He did have a rubber band ligation procedure done at the end of August to fix hemmorids.
Posted Sun, 9 Feb 2014 in Urinary and Bladder Problems
 
 
Answered by Dr. V. Sasanka 2 hours later
Brief Answer: Needs a biopsy asap Detailed Answer: Hi, Thanks for your query. Irrespective of Free PSA levels, a total Serum PSA of 26 is an indication for transrectal ultrasound guided prostate biopsy. even if a digital rectal exam is not suspicious. there is only major no-no for a biopsy when there is an active evidence of infection in bladder or prostate which can indeed elevate PSA to levels seen in malignancies, but in these situations, the PSA does come down once the infection settles down, and also patients also would have resolution of some of the symptoms they might have had earlier like lower abdominal or perineal pain / discomfort, fever, urinary voiding symptoms. Another thing that many people believe is that patients should have symptoms of any malignancy. Unfortunately this does not happen in early prostate disease, and quite a few patients are fairly healthy at the time they are diagnosed to have a metastatic prostate cancer. Thus, I do not want to sound alarmist, but my sincere suggestion is act on the fact that his PSA has gone up, (and forget Free PSA levels, they are more useful in doubtful cases where the Total PSA is between 4 and 10 ng/ml). Even if there is no evidence of malignancy in a biopsy, please do repeat PSA again after another year, and maybe even another biopsy as there is a significant likelihood (nearly 20-30%) of missing a malignancy even in the best of hands. Once your dad is over the age of 75 years, you can take the call as to whether you continue checking for prostate cancer as several urologists believe that screening should stop after 75 years, but in your father's case I would still suggest that you get a regular check. Hope I have been able to help you. Regards.
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 1 hour later
Dr. Sasanka, Thank you for taking the time to answer my questions. I had a few more if you don't mind. 1.) Can BHP be attributed to such a spike in total psa numbers? 2.) Can an occult infection be present? 3.) Can any other factors raise this psa (i.e. inflammation from hemmorid, rubber band ligation four months ago)? 4.) Have you seen PSA in the upper 20's, and were they mostly indicative of aggressive cancer; or can it be a non-aggressive finding? 5.) Does the sonogram detect a visual image of a tumor? 6.) Why would my dad's total psa's spike, but his free psa's also rise? Here are my dad's numbers: mid dec 2013: total: 26, free psa 54% early dec 2013: total: 23, free psa 55% early oct 2013: total 9, free 45% oct 2012: total 3.2, frew 35.4 % Oct 2011: total 2.3 7.) Does BPH have no symptoms in some men? 8.) Could my dad's prostate become larger; from BPH, within this short time frame, and cause spikes in total psa? 9.) Have you ever seen BPH be the cause of such jumps in PSA #s? 10.) Does the body sometimes cause PSA to spike from an irritation, or infection? Thanks!
 
 
Answered by Dr. V. Sasanka 6 hours later
Brief Answer: BPH unlikely to cause such a high PSA Detailed Answer: Hi again, Wow! So many questions, but I will try and answer all of them. BPH can cause an increase in PSA - sometimes a massive prostate in a symptomatic patient can cause PSA to go up to over 10 ng/ml witout any evidence of malignancy. But this is something that we factor in when we give recommendation for a biopsy. Thus a 100gm BPH can cause PSA to reach 10 rather than a 20 gram prostate - this is called PSA density. Occult infection can always be present and is quite probable in your case as the rise in PSA seems quite rapid, including a rise in free PSA, and there is a good case for starting him empirically on a course of antibiotics for a couple of months and reassessing his PSA, and biopsy only then, if required. The risk of biopsy in an infected prostate goes up considerably, and this risk can therefore be minimized. Ligation of haemorrhoids could have caused a transient, mild elevation in PSA but it would be unusual to have caused such a sustained rise unless there has been some major complication which looks very unlikely considering that you mentioned that your father seems fairly asymptomatic. A PSA of 20+ is not necessarily indicative of an aggressive cancer. To some extent, a very rapid rise in PSA over a course of time indicates aggressiveness, but the measure of how good or bad a tumour is can be obtained only from a biopsy where there is a score called Gleason's which predicts how is the course of disease likely to be. The sonogram was thought to detect a visual image of cancer, but now we know that it is more useful to direct a biopsy. I saw the PSA levels, and to some extent am encouraged and think there is possibility that some infection might have caused this spike, and therefore would recommend a longer term of antibiotics like Ciprofloxacin for 2 months and reassess PSA. Free PSA being high is encouraging, but we prefer to avoid it in patients where the PSA is over 10 ng/ml - it has confused issues quite often earlier. BPH can produce no symptoms in many men, while some men do notice symptoms and are not bothered by it till late, because they happen gradually over years. BPH usually does not increase so rapidly over a short span of 3 months, and I have personally never seen such a case. As I said earlier, PSA can be spiked from a prostate or seminal vesicle or bladder infection. So antibiotics are indicated here. Hope you are slightly better off now after these details ;-)
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 12 hours later
Dr. Sasanka, Good morning! Thank you SO MUCH for answering all of my questions. I truly appreciate it. I am almost all questioned out, and will just continue to pray that everything turns out okay for my dad. Here are a few more questions: 1.) Does blood work ever detect an infection(s) in the bladder, seminal vesicles, and/or prostate? Dad's bloodwork is excellent. The MD/Urologist said that he has no infection, but perhaps there can be very tiny infections which cant be picked up by such bloodtests. Also, wouldnt white blood cells go up with an infection? How probable/likely would an infection be without any symptoms in your experience? 2.) Have you ever seen such spiking scores, with a tumor, and it still being staged, after biopsy, with a low grade, or is it more typical, that such spikes are usually not such a good sign, and perhaps shows a spread of cancer? 3.) Given the fact that prostate cancer is slow growing, is it very likely to have an aggressive tumor with such spikes? 4.) If this is a tumor, would radiation completely eradicate the cancer? 5.) With radiation, is it still possible to undergo treatments with a pacemaker? Any modifications needed? Thank you!!!! Dr. Sasanka, Good morning! I forgot to ask a question. You had mentioned that it may be XXXXXXX for someone who has a prostate infection to have a biopsy. How so? Would this cause more problems, and accelerate an infection by placing needles in there? Also, wouldn't the MD be able to assess such infections with possible pain felt by my dad during a Digital Rectal? thanks! XXXXXXX Dr. Sasanka, Good morning! I forgot to ask a question. You had mentioned that it may be XXXXXXX for someone who has a prostate infection to have a biopsy. How so? Would this cause more problems, and accelerate an infection by placing needles in there? Also, wouldn't the MD be able to assess such infections with possible pain felt by my dad during a Digital Rectal? thanks! XXXXXXX
 
 
Answered by Dr. V. Sasanka 28 hours later
Brief Answer: Biopsy infected prostate - may have serious sepsis Detailed Answer: Hi, I will answer your last question first - Biopsy of a prostate in presence of sepsis can cause the infection to spread to the rest of body. Hence, if there is infection, treat with antibiotics, confirm sepsis is better, and only then the biopsy ought to be performed. Blood work can suggest acute prostatitis, but infection of seminal vesicles is rare and sepsis of other accessory glands could be impossible to detect. As I have said earlier, the pattern of PSA results in the case of your father is rather unusual, which leads me to hope that this is unlikely to be a tumour. I think the other questions would be superfluous at present, and could only lead to distress at this point, and I would rather have a repeat value of PSA and if required a biopsy rather than theorize about probabilities.I mean why think and bother regarding radiation when there is at least some reasonably good chance that there is no malignancy? Hope I have been able to help you again.
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 23 minutes later
Dr. Sasanka, I want to truly THANK YOU for all of the information which you have shared with me. I always have a very special place for Medical Doctors' in my heart! The work that a good MD does is insurmountable! I am going to take your advice, and calm it down. I just wanted to let you know that my dad's urologist's nurse stated that they were able to detect no occult infections due to their bloodwork on my dad coming back normal with red and white blood cell count. I am not sure if Sepsis would not be picked up on such tests. I still feel that something had gone wrong during his rubber band ligation procedure. Perhaps the body could do weird things, and this inflammation has no known cause. Have a very happy and healthy New Year!
 
 
Answered by Dr. V. Sasanka 10 hours later
Brief Answer: My pleasure Detailed Answer: It always has been a pleasure when we have been able to comfort and aid any of our patients, and luckily, this long distance patient-doctor relationship seems no different. I hope your father does well, and I would be grateful if you could let me what is happening to his PSA and other reports about 2-3 months from now. Wishing you and your family the very best of the new year. Regards.
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 30 hours later
Dr. Sasanka, Happy New Year! I just wanted to ask you, if there is no sepsis infection, which my dad has no symptoms of, what other types of infections have you seen which are occult? Is there a chance that there may be no obvious reason, for such an increase in total PSA? Does the body sometimes create a temporary inflammation, with no known etiology? Have you ever seen such jumps in PSA and it turns out to be cancer? Thank you!!!!!!!! :)))))))))))))))))
 
 
Answered by Dr. V. Sasanka 3 hours later
Brief Answer: Abrupt jumps in PSA unlikely to be cancer Detailed Answer: Hi, Again, to answer your last question first - the reason I thought there is some encouraging news is because PSA in October was 9 ng/ml, and in December 23 ng/ml. This almost always never happens with Cancer, and could certainly happen with infection of prostate or other accessory glands. Now he has no symptoms, which while odd, is certainly not impossible, and should the PSA come down to, say 9, three months from now after a course of empirical antibiotics with Cipro or Levofloxacin, you know that this has been a false alarm. Nevertheless, a transrectal ultrasound is indicated, and a biopsy should be done under it's guidance, with appropriate antibiotic cover, especially if they find some nodules. Hope I have been able to reassure you.
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 9 minutes later
Dr. Sasanka, Thanks again! I appreciate your reassurances! Another good thing is that my dad's DRE did not reveal any nodules. I know that this is not a perfect indicator of possible tumor(s), it may also be a good sign. If it was an aggressive cancer, I am assuming it would be felt on exam, or sometimes cancer can be agressive. I will continue to pray, but since I am assuming that you have never heard of a person developing such an aggressive prostate, I will continue to remain positive! Sincerely, XXXX Dr. Sasanka, How are you? I hope all is well, and you are having a great New Year! My dad had his biopsy sonogram today. The MD did not find any nodules on the Sonogram, but he still feels my dad will have an end result of cancer. He said that most men, in my dad's age range, will develop Prostate Cancer. The MD also said, because there were no visual signs of a tumor, on the sonogram, he decided to take not 12, but 18 samples. The MD also stated that free % does not really help my dad in this situation. He also stated that if my dad did have an infection, with such high PSA numbers, it would be exhibited in him feeling very sick. I just wanted to again ask you if you can still have an occult infection, without having any symptoms. This dramatic jump in total PSA levels, with no nodule being felt on the Digital, and also no visual images of lesions/tumors on sonogram, excellent free % psa's, then why is this considered such a likely cancer by the MD? Does inflammation show up on a sonogram? I am not sure what else could be causing these jumps in PSA? Thanks! XXXXXXX
 
 
Answered by Dr. V. Sasanka 4 days later
Brief Answer: I will still go with infection Detailed Answer: Hi again, Once the urologist starts taking so many biopsy cores (I mean, a count of 18 is indeed very high), there is indeed a chance of picking up cancer in at least a few of them. Many normal men with normal PSA levels might have foci of cancer if 18 biopsy cores have been taken from them too. The question is, how relevant to his health will be any cancer so detected. So I would be quite happy of they detect a cancer in one or two cores out of 18, but if 12-15 cores show cancer, then you know there is trouble. The good news is most prostate cancers are indolent, and depending on the biopsy report, we actually can predict the course of the disease. And there are newer drugs which have come in, like Abireterone, which have significantly reduced mortality due to prostate cancer. (Though it is quite expensive, I must add). As you have listed, the sudden upswing in PSA values just does not go with my experience of prostate cancer, but I will not pretend to be the expert here. the Free PSA does not help much, but cannot be neglected. As I said earlier, it is more likely to be useful if PSA was between 4 and 10 ng/ml. Inflammation does show up on sonogram as areas of increased vascularity, but so does cancer. Bye for now, and let me know if the biopsy report has been contributory, and if there is any clarification required, i shall be happy to provide. Regards.
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 17 hours later
Dr. Sasanka, Thanks again, and I pray that your feeling about it being an infection holds true after biopsy results come back. Is it possible to have an occult infection, and it not be detected on the sonogram? Does radiation usually do the job in killing prostate cancers, or does it depend on the aggressive nature of it? I wonder if an undetected, benign growth of some sort, like a polyp, could appear in the prostate and create such a spike in psas? Also, I am worried about perhaps cancer of the rectal area could be creating these psas to rise? I am assuming these organs and areas were all checked during the sonogram on Monday, and also with the Gastroenterologist in August. You have been a VERY SPECIAL person for taking the time to answer ALL of my MANY, MANY questions. If you are ever in New York City, I would enjoy the opportunity to thank you in person!!!!! T
 
 
Answered by Dr. V. Sasanka 2 hours later
Brief Answer: Cancer of rectum unlikely Detailed Answer: Hi, Again I shall try and answer your last questions first. It does not look like a cancer of rectum certainly. This would not cause PSA to go up so dramatically, though a mild increase may be expected. And again, cancer of rectum is not as indolent as prostate cancer, and can get quite troublesome fairly early in its course. PSA rise and polyps? Hmmm... Does not sound probable at this stage. Radiation does an EXCELLENT job of killing prostate cancer, and even an aggressive tumour usually disapperas fairly fast once the treatment has been started. I would advise you to stop worrying about all this right now. You have taken the decision for a biopsy, and it is done, and so there is definitely going to be some news in a couple of days. We can answer all your questions more specifically once we have some concrete information. Hope your father is doing well, and has no significant side-effects of the biopsy like a fever or urinary disturbances. It will always be a pleasure to meet you, and I can assure you that it i would definitely look forward to meeting you should I come to NY, which may happen in 2015, or should you ever travel to my place, which is Hyderabad in South India. Regards.
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 18 hours later
Dr. Sasanka, I want to thank you, again, for your continuous kindness, and professional answers to my million and one questions! Tomorrow I will share with you, HOPEFULLY, great news from my dad's biopsy. This will all be figured out, I hope, by tomorrow. My last questions are: 1.) Can an occult infection not be detected on a sonogram of the prostate (TRUS)? 2.) How can the biopsy pathologists detect, from these core biopsies, if it may have spread to neighboring areas (seminal vesicle, etc)? In 2015, I will be more than happy to show you around New York City! Have you ever been? Sincerely, XXXXXXX
 
 
Answered by Dr. V. Sasanka 11 hours later
Brief Answer: Difficult on TRUS to detect small infection Detailed Answer: Hi again, An occult infection will be difficult to detect on TRUS. Also TRUS is not foolproof, and even in the best of hands, cancer bearing areas can be missed, and areas of sepsis are mistakenly thought to be cancer and biopsied resulting in massive streaming of blood by bacteria causing severe morbidity. At best, it can be used to guide a biopsy, with the understanding that not all nodular appearing lesions are cancers, and not all cancers are hypo-echoic nodules. On the TRUS guided biopsy, the pathologist looks for something called 'perineural invasion' along with the other info such as cancer grade, extent of involvement, how many cores, etc.. This can be readily assessed by one with experience. I doubt if even an experienced pathologist can give anything beyond this though. i mean seminal vesicle involvement can be assessed after a radical prostatectomy specimen reaches the pathologist or maybe on a pre-operative MRI scan by a good radiologist. Cheers for now,
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 14 hours later
Dr. Sasanka, Good evening! I wanted to share with you the shocking biopsy results, and ask your opinion on all of this. I am quite upset. Out of the 18 core biopsies, half came back positive for cancer. In particular, the MD stated two tumors were discovered; one with a XXXXXXX score of 7 and the other a 9. These tumors were found on the sides of the prostrate. I am very concerned. The MD said the next step is a CT scan and also a bone scan. My dad has a pacemaker, and I am not sure if the bone scan involves Magnetic Resonance Imaging. Do you think, with this aggressive spiking, that my dad could have had this cancer spread to the spine, bones, and/or lymph nodes? I asked the MD if this, God forbid were the case, he stated the spread could be treated with hormonal therapy? Is it possible to treat a spread to bone and/or lymph node with hormonal therapy? Would this hormonal therapy decrease the tumor cells? I am not sure if cancer staging can be provided from this biopsy, or do they wait until the CT and Bone scan are done? What are the chances of this aggressive cancer being encapsulated? Is it determined by the CT scan, or can the biopsy determine this? Can regional or distal spread take place within a short time frame? I am concerned about time of being of the essence here. Should I worry about a week or two making a difference? Would you recommend a complete removal of the prostate gland in aggressive cancers, or is radiation and hormonal treatment enough and equal to prostate removal? I know that this is an over abundance of questions for you. I am just so upset by all of this. Thanks again! XXXXXXX
 
 
Answered by Dr. V. Sasanka 4 hours later
Brief Answer: Do not worry Detailed Answer: Hi While it is unfortunate that he has a cancer, most prostate cancers behave reasonably well and do not necessarily represent a poor outcome straightaway. Most are hormone sensitive and the PSA levels plummet once the male hormone testosterone is blocked from action. Before doing this I suggest you get the tests recommended by the Urologist. CT scan should not be an issue even in patients with pacemakers and a bone scan will help in follow up as well. The prognosis is not bad at all and there are newer medications available even in the event of the disease getting independent from hormone manipulation. Hope I have been able to reassure you to some extent.
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 4 hours later
Dr. Sasanka, Good morning, and thanks for the reassurance! I had a few more questions (as usual): 1.) Do you think radiation and hormonal therapy is the way to go, or a complete prostate removal? 2.) With such high XXXXXXX and PSA scores, do you think these tumors have already metasticized? 3.) If it has spread to the bone or lymph, how do they treat it? Thanks! XXXXXXX Dr. Sasanka, Good morning again. For peace of mind, I have compiled a list of questions. I do not want to exhaust you, but if you could please find the time to answer them, I feel I would be more at ease. No rush though! Thanks a million! XXXXXXX 1.)Do you think, with this aggressive spiking, that my dad could have had this cancer spread to the spine, bones, and/or lymph nodes? 2.) If spread, what is the probability, and also how is it treated (i.e. hormonal therapy)? 3.) Have aggressive, or various other levels of prostate cancer not been effectively treated with radiation and chemotherapy? 4.) Is it possible to treat a spread to bone and/or lymph node with hormonal therapy? Would this hormonal therapy decrease the tumor cells? 5.) Can cancer staging, and also the possibility of cancer spread be determined by biopsy? 6.) Can regional or distal spread take place within a short time frame? 7.) I am concerned about time of being of the essence here. Should I worry about a week or two making a difference? 8.) Would you recommend a complete removal of the prostate gland in aggressive cancers, or is radiation and hormonal treatment enough and equal to prostate removal? I have been reading that by removing the prostate gland, one can more readily and fully detect the full pathology of the prostate. 9.) What is the survival rate? 10.) How long should I wait before starting these radiation treatments? 11.) How does hormonal treatment work on possible spread to bone and lymph nodes? Does it completely eradicate, or rather just slow down the cancer? 12.) Have you ever seen such high XXXXXXX numbers, with such high PSA spikes, and if so, what has been your understanding of how this treatment will work with such a challenging combination/aggressiveness? 13.) When you say the two tumors were found on the sides of the prostate, does this mean it has a poorer prognosis, and more of a chance of spreading? 14.)If half of the biopsies were negative, is this a good sign? Dr. Sasanka, Good evening! I just wanted you to see the results of my dad's biopsy. Please let me know what you think. Perhaps you can explain about the perienial nerve involvement. Final Diagnosis: 1.) Prostate-left apex-biopsy -Prostate tissue with a small focus of atypical glands. 2.) Prostate-left mid-biopsy -benign prostate tissue 3.) Prostate, left base, biopsy -Adenocarcinoma of the prostate. XXXXXXX score 4 +3= 7 involving 20% (1.5 mm in length) 1 of 2 core(s) 4.) Prostate, right apex, biopsy. -Adenocarcinoma of the prostate. XXXXXXX score 4 +5=9 involving 95%, 95%, and 60%). (5.5 mm, .5mm, and 4 mm in length) of 3 of 3 core(s). -Perineural invasion is identified. 5.) Prostate, right, mid, biopsy -Adenocarcinoma of the prostate. XXXXXXX score of 4+5=9 involving 95% (7 mm in length) of 1 of 2 core(s) -Adenocarcinoma of the prostate. XXXXXXX score of 4 +3=7 involving 80% (8.5 mm in length) of 1 of 2 core(s) - A total of 2 of 2 cores involved in carcinoma. 6.) Prostate, right base, biopsy -Adenocarcinoma of the prostate. XXXXXXX score of 4 +4=8 involving 85 and 70% (10 mm and 7 mm in length) of 2 of 3 core(s). Thanks, XXXXXXX
 
 
Answered by Dr. V. Sasanka 4 days later
Brief Answer: Hormonal manipulation ideal. Radiation might help. Detailed Answer: Hi, I guess the fact that there are foci of tumor having Gleason's score 4+5 is not too great, effectively meaning this is an aggressive cancer, but as I mentioned earlier, most urologists would be hard put to put a time frame for prognosis here, as many such tumors also respond very well to hormonal manipulation, and you will find PSA dropping dramatically once he is started on appropriate medication. This usually will not be a cure, but will help achieve a control. Ii would be like trying to hold on to a galloping horse- you could get three people to do it for an hour, but the horse will eventually get away, and you bring in some more people, and hold it back again. How many people you recruit for controlling this galloping horse will be a test to your resources, financial and otherwise. For example, we are now seeing results from the use of a new drug called Abireterone (which is ridiculously expensive) which is being prescribed for people who have had their prostate cancer escape from the effects of hormonal manipulation after a year or two of initiation of therapy with very good results, fingers crossed. We are in early days yet, and I guess eventually the stupid cancer will win, but what I wanted to tell you is that newer therapies are available which did not exist till a couple of years ago, and newer therapies are likely to come in in the next two three years as well. There is a reasonably high chance of the tumor having metastasized to the bone, and lymph nodes, which can be picked up on MRI, which is better at staging of cancer, though the biopsy has given an indication that the tumor is indeed aggressive. There are so many questions, and I guess you must be trying to clutch at some good news, which is indeed there. Only half the cores are positive, and not all cores are as aggressive as 4+5. I can assure you, I have at least a couple of patients, who started with PSA of 60s, and score of 3+4 and 4+3, who are into their 6th year of treatment, and they are doing very well. They do have issues, I mean the hormonal manipulation takes away sex drive, energy levels drop, but the main thing is they are still in our midst, and happily gassing away, and exchanging greetings with me very new year. the PSA dropped to 0.1, and a year or two later, went up to 5-6, and we started some newer medication, stopped some older ones, and now it is back to 0.3 or so. Sometimes I wonder if they think I am a bit of a cuckoo, for having been scared for them when they presented initially but the point I am making is do not be alarmed, and you need not worry about any rapid deterioration (Usually Ca Prostate is an indolent disease). You can make plans for th future, some trips, etc. as long as you are keeping in touch with your local Urologist / Oncologist. Let me know if I can be of more use.
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 40 minutes later
Dr. Sasanka, Thanks for taking the time to answer my questions. Do you think the hormonal therapy will work? The Oncologist yesterday stated that he probably wouldnt perform radiation if it has spread? How come? Would it not hurt to control it better? What do you mean by it being an indolent disease? Does this mean that it can never kill you? Also, since my dad has no symptoms, nor pain, and the Oncologist felt his prostate yesterday, and did not feel any lumps, he thinks that it may still be contained? What do you think about the Cyberknife vs. traditional radiation therapy? Thanks! XXXXXXX
 
 
Answered by Dr. V. Sasanka 4 days later
Brief Answer: I am sure Hormonal therapy will work Detailed Answer: Hi, Sorry for the delay in responding. I was away on a training for the past 3 days. Yes, I think the hormonal therapy will work, but you will need to be on close follow up. I am sure the oncologist is right in mentioning that radiation or any form of local therapy is not really going to be useful if the disease has gone beyond the prostate, which it could have considering that the disease seems to have progressed rather fast, but in a way, these are the tumors which shrink rather fast and show response to the treatment too. When I meant indolent, I meant that unlike say, a stomach cancer or colon cancer which could prove fatal in a space of a few weeks if they have extensively gone beyond the native tissue, prostate cancers show a less aggressive trend usually and many patients are actually doing well even 2-3 years on treatment after they have been detected to have metastatic disease. I did not mean it would never kill you, but in the kind of age group who suffer from prostate cancer, several patients have a reasonably good quality of life despite harbouring what would have been a terrible disease without treatment. I think the Cyberknife or traditional treatment question would have been answered by now by the treating Radiotherapist. Essentially, a cyberknife will spare normal tissues to the maximum, and doses only the cancerous prostate, thereby minimizing side effects originating from bladder and rectum which could XXXXXXX patients of a good quality of life. Obviously, this is expensive compared to conventional radiotherapy. Please let me know how your father is doing.
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Follow-up: What could be the reason for increase in Prostate-specific antigen levels? 3 hours later
Dr. Sasanka, Good morning! How was your three day seminar? Thanks for always being upbeat! 1.) Do you think that my dad probably had this cancer for a very long time? The Oncologist seems to think so. Also, it has metastasized all over his bones. How can that occur within a few months? I am praying that it may have been in his sytem for a very long time. If his prostate cancer has been in his system for so long, then the most recent elevation of PSA may not be the best marker here when assessing how future hormone treatments may be working to suppress the cancer. For example, say the PSA drops significantly (Im praying for this), but this crazy, aggressive cancer is spreading elsewhere; hence the PSA, perhaps in my dad's case, may be creating false negatives. Is there any other test to assess what is going on? 2.) My dad has to take Caltrate, for his bones. He is taking 1200 mg, once in the morning, and then again in the evening. He says that he is feeling not so great with the fact that the Caltrate (Vitamin D and Calcium) sits in his stomach? Any suggestions? I also read that this Caltrate can sometimes promote more prostate cancer growth in particular with bone metastasis. 3.) Do you feel that hormone treatment(s), more than likely do not work after awhile? Have you known of any patients, with my dad's aggressive prostate cancer, to actually do well with hormonal treatment? I just worry about how quickly this disease has progressed. 4.) I know that no one can predict such an outcome, but, with your patients that you work with, in Stage IV, with Gleasons 7, 8, & 9, and a rapid spike in PSA's, how many years have they been surviving to this date? 5.) Would u know of any patient of your's, in my dad's situation, that would be willing to email me about their experiences living with this disease? 6.) Also, which specialist would know more about the prognosis of prostate cancer? Would it be a Urologist or Oncologist? My dad's Urologist is more upbeat about this disease, stating that it will not kill him, and he can live another 15 to 20 yrs, but the Oncologist was pessimistic. He stated indirectly a survival of 6 years. 7.) If the hormone treatment does not work, then can the Chemotherapy drugs prolong life for many more years, or is it in months? 8.) What types of foods/diet do you recommend? For example, I heard TOFU is a cancer slower? AS ALWAYS, I truly THANK YOU For your time! I feel so relieved when you provide me with optimism during such a difficult time!!!!!! Sincerely, XXXXXXX Dr. Sasanka, Hi again! I had one more question. 9.) The Oncologist mentioned that even with Cyberknife radiation, my dad may develop Bladder Cancer from this radiation. What do you think? Thanks! XXXXXXX
 
 
Answered by Dr. V. Sasanka 20 hours later
Brief Answer: Hormonal therapy still the best bet Detailed Answer: Hi, It is almost certain that the prostate cancer has been there for a while now. in its early stages, it is extremely silent, and that is the reason we suggest careful screening of men over 50 years with the blood test PSA. If your father is not comfortable with caltrate, he can have a bis-phosphonate injection like Aredia once a month if his kidney function is normal. The oncologists are fairly conversan with this, you can bring this up next time you visit them. As I said earlier, the hormonal treatment is like trying to hold on to a galloping horse. After a while, you need additional drugs, but the cancer is more likely to win. the question is when, and we find that the PSA level is an excellent indicator. Earlier, we did not have drugs like Arbiterone but now that it is available freely with knowledge of side-effects and use, we find that many patients who would have reached a hormone-unresponsive stage can pull along for more months. this does not guarantee immortality, and the aggressive nature of cancer in the case of your father makes me a bit cautious in prognosticating your father's course, but I will take any survival more than 5 years as acceptable, though as I have said, I am pleasantly surprised when my patients do very well many years after starting treatment with PSA well below 1 ng/ml, and I actually feel a bit foolish when I think I might have caused them and their families unnecessary alarm. I could get you in touch with at least 3-4 of them, but the problem would be in communication - most are not conversant with English, though very erudite in our native lingo. The Oncologist is right in saying cyber knife has its disadvantages, though causing a bladder cancer sounds sort of far-fetched. I expect some degree of irritative voiding symptoms after the therapy when they will be voiding urine frequently, and with pain, and maybe blood in urine as well. I doubt if any particular food will be more helpful at this stage, but I guess food having lots tomatoes containing Lycopene is the best bet. Tofu is healthy even otherwise, and even I see no reason to deny him anything which he likes. Once the effect of hormonal therapy starts to wane off, the chemotherapy agents will be able to prolong life for a few more months, though it is balance between side-effects and utility at that stage. I would rather have my patients be comfortable towards their end rather than be bedridden for a few extra months, though many people, especially Medical Oncologists, might disagree with this.
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