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Suggest treatment for Prostate cancer
Question: Dr. Sasanka, Good morning! How are you? It's XXXXXXX (re: my dad with the prostate cancer). I was informed by a Prostate XXXXXXX 9 , support member, that XXXXXXX 9's, with bone metastasis, need to not only be tested with PSA, but also four other blood tests (CEA-CarcinoEmryonic Antigen, CGA-ChromoGranin A), NSE (Neuron-Specific Enolase), and PAP (Prostatic Acid Phosphatase). I was wondering if people, on this thread, have their Oncologist's take this extra blood work. My dad had this sneaky cancer come out of no where! His PSA was always low, and his PSA just started to jump like crazy within 4 months. I believe that my dad's entire skeletal system had to have this cancer on it for years. I thereby feel that PSA alone, will not be a full indicator if it lowers to close to zero (I pray), but rather looking at the above mentioned bloodwork. Also, has anyone with stage IV, bone metastasis, ever had radiation done, even after cancer had spread out of the prostate capsule? Thanks!
Brief Answer: PSA alone not the best, but most convenient Detailed Answer: Hi again, I do understand your concern, and in fact, I should admit that I was surprised that your father had such an aggressive cancer with XXXXXXX score of 9 with an extremely unusual spurt of PSA in a very short interval. Unfortunately all the other markers that you mentioned are also not very specific, and are more suited for academic centres and research facilities. PAP, for example, is a test which evolved the first, and has almost been given up after the emergence of PSA. The rest are relatively new, and I should admit that an oncologist will be in a better position to guide you as to their utility in assessing the cancer's response to treatment as they frequently ask for these tests in cancers other than prostate. Radiation to the prostate at this stage is not something I would have recommended under normal circumstances, but recently I had a prostate cancer patient, a local VIP, whose PSA in November 2012 was 63 with extensive bone mets, and is presently on endocrine manipulation, and had PSA dropping to 1.2 by Nov 2013, but has started to go up to 4.3 this January 2014. This particular patient had been recommended second opinion, and they reached a radiotherapist at Sloane Kettering, NY who apparently thought 'mild' local radiation to prostate is still a good idea. I was doubtful because this could severely compromise his already obstructed urinary voiding, possibly causing him pain and increased urinary frequency with possibility of stinging bowel motions also even despite the best of Cyberknife or whatever technology. I indicated as much, and said that the call should be by the patient and his family, especially when there have not been too many patients who showed dramatically good response at this stage. I also admitted that there would be better and more experienced people, and therefore third or fourth opinions also could be taken before committing him to radiotherapy. Either way, I see no reason why he should not be started on the endocrine manipulation as early as possible. I think he should be started on drugs like Casodex for at least 10-14 days before you start him on Depot Injections, and see how is the response, initially with PSA, and may be later, the other markers, if the oncologist feels happy about using them to follow up. Hope I have been able to help you.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Dr. Sasanka, How are you? I hope you are having a wonderful Sunday! Thanks for your expedient responses!!!!! My dad has been on Lupron since January 16th. He is going for his bloodwork PSA check on February 28th. Do you think this is enough time to see if his Lupon is working? Also, my dad is very healthy, aside from this terrible disease. He does not have any urinary issues. Do you think he would be a candidate for radiation therapy as a non-presenting, healthy person? Also, can radiation be done in the same location at another time, or is it a one time deal? Do you think that this prostate cancer could have been on my dad's bones for years? It is so extensive, and I just cant believe that, even though the PSA just started to spike a few months ago, that this could travel so quickly throughout the skeletal system? Even though there is extensive metastasis to bones only, perhaps it has been there for years, and his prostate cancer may not be as aggressive as we think? Do you know of anyone, in my dad's clinical situation, that is doing well with Lupron shots alone, for a decade or so? The Urologists which I have seen, feel that this is not a death sentence for my dad, but the Oncologist's are not as upbeat. The Oncologist's throw out statistics of 6 years. How come the Urologists say my dad can live with this for a decade, and another Urolologist says 15-to-20 years? How is this possible (although I hope they are correct) with a stage IV? Thanks!!!!!!! XXXXXXX
Brief Answer: Urologists see more patients of CaProstate Detailed Answer: Hi, We as urologists see more patients of Prostate cancer than the oncologists, as the pick up is usually by the urologist when they start investigating for what would be a routine prostate enlargement. Therefore, most patients are initially treated by Urologists, and therefore we do see the patient in their best time which is soon after the depot injections have started their work. More of than than not, the depot injections will stop working after a variable time, usually after 18 months after initiation of therapy, but on occasions earlier, and on occasions much later, depending on the biology of the cancer. There usually will be a rescue medication, and that will go on for another year or two, and it is only then that the patient actually is handed over to the medical oncologists to try chemotherapy. this could explain why we urologists are relatively more optimistic, and do not feel that this is a death sentence for the patient. The odd patient does poorly, and there are odd patients who do very well exceeding our expectations, as I said earlier. I mean, I have a very sweet 70 year old man who has been my patient for at least 6 years now, after an initial diagnosis of CaP with PSA 69 with bone mets in 2007, who comes on dot every 3 months. His PSA started climbing up as per schedule 18 months after endocrine treatment was started, and I juggled with medications, and I had to actually start him on feminine hormones which were not expensive, as he had no monetary support to afford fancy chemotherapy, and for the past 5 years, his PSA has been maintaining below 0.1 ng/ml. He waits timidly, knowing that I will ask him to lie down for a digital rectal prostate examination, and once it is done, starts sobbing quietly into his handkerchief as he gets emotional and feels that he practically reborn. This scenario is not unique, and I remember my chief having had patients who have been following up for several years. I distinctly remember thinking on one occasion that this particular patient may not make it till next visit, and it is indeed a pleasant surprise to find them pulling along. i should admit that the disease in India and the rest of Asia may not be as virulent as seen in the Western world. I also feel quite pointless right now thinking of how long the disease might have been in your father's system as it is not likely to benefit anyone, and will be only like twisting a knife into a wound. Best course would be to enjoy the time he has with you quite productively, and see if he has any unfulfilled wishes, for example, travel, cuisine, hobbies, the works. You need not crowd him into a schedule, as please understand that he has many more valuable months of life still inside, but instead let him choose the pace. Hope he will not require radiation. Usually it is a one time deal. I would definitely look for 3rd and 4th opinions before committing to radiotherapy at this stage. Regards and best wishes.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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