The Times: Thomas Stuttaford on PC

From Kidney Cancer Resource

Contents 1 Overview 2 Articles 3 2006.05.16 Questions & Answers on prostate Cancer 3.1 Comments @ TimesOnLine 4 Disclaimer 5 E&OE - Errors & Omissions Excepted

Overview

To Read The Times OnLine Click Here

Dr. Thomas Stuttaford

Articles

2006.05.16 Questions & Answers on prostate Cancer

Dr Thomas Stuttaford answers your questions on prostate cancer The Times doctor explores readers' concerns about prostate cancer ONLINE CONSULTATION: the doctor's next topic is Prozac and antidepressants. For how to e-mail your question for answer online on Wednesday and to read other recent topics click here.

Note from Dr Stuttaford: As with all the questions we answer, we have to deal with the underlying principles that the question highlights rather than a special case. We don't know the details of any correspondent's medical history, nor can we examine them. Only a patient's own GP, oncologist or urologist would be in a position to explain the treatment recommended that may well, quite rightly, be different from the usual practice.

I developed prostate cancer in 1998 (age 61) and was treated with radiotherapy the same year. My PSA reading dropped immediately to less than 1.0 and remained at that level until 2003, when it began a slow rise (with occasional reversals) to 9.0 in November 2006. My consultant has been monitoring my PSA with a view to an eventual commencement of hormonal treatment. I have not been told what level of PSA will trigger the hormone medication, and I am concerned by recent media reports of cancer treatments being started too early, simply to let NHS people tick the 'treatment in progress' box. What is the PSA number that, in your opinion, would represent the optimum level at which medication could commence? Michael Hewitt, Ousden, Suffolk

You and I had our prostate cancers diagnosed at much the same time and so I read your letter with great interest. The good news is that your PSA dropped so rapidly after the radiotherapy. It never returns to its lowest point immediately, but the faster it does the better the outlook, and the more likely that the initial tumour has been well zapped.

Related Links Dr Thomas Stuttaford answers your questions on thyroid problems Dr Thomas Stuttaford answers your questions on NSAIDs Dr Thomas Stuttaford answers your questions on home births As in your case my PSA, after a radical prostatectomy rather than radiotherapy, began to climb after about five or six years. My consultant and I belonged to the school of thought that believes that the PSA should preferably be treated with hormones once it has reached one or two, after starting, in my case, at less than 0.05. For me, this corresponded with an increase in the speed at which the PSA had begun to rise. Any acceleration in the rate of rise in the PSA is always an important factor in determining treatment. Patients who have radiotherapy as their initial treatment will rarely have such a low PSA after therapy as those who have an apparently successful radical.

I don't think you need be concerned that GPs and oncologists will start hormone therapy early just so that they can tick the box for treatment in progress. The other side of this is that by not having hormone treatment early the NHS is saving several thousand pounds a year. In my opinion, the advantage of early treatment is that there does seem to be some, possibly debatable, evidence that starting treatment sooner rather than later may give the patient a slightly longer period of remission.

The disadvantage is that a patient has to put up with the side effects of the hormones for a longer time. As in every branch of medicine there is always a balance between the advantages and disadvantages, and where this balance is set is a matter for discussion between the doctor and the patient. I was impressed by the thought that starting hormones with a PSA of between 1 and 2 has in some studies been shown to give a fractionally longer period of remission. Many of my patients have taken the other view and decided to have a longer period without the inconveniences brought on by hormone therapy.

My prostrate cancer was diagnosed in 1997 after a biopsy. Radiotherapy treatment followed. My PSA readings fluctuate summer and winter, but have now recently increased to 2.4/2.5. Is this fluctuation unusual and does the increase indicate that the cancer may be returning? Roger Gillham, Windsor

After radiotherapy, especially with the doses given in 1997, it is unusual for the PSA level to reach levels of less than 0.05 per cent. That a PSA reading has remained constant between around 2.4 and 2.5 for ten years is an excellent result. If your PSA is beginning to show a steady increase, (this wasn't absolutely clear from your question), it is a matter that needs to be discussed with a patient's oncologist. Doctors are usually alerted to a possible change in their patient's condition if they have three or more PSA results that have risen when tested at agreed intervals. Always remember that there are other factors that might have caused an increase but never take a chance.

I am 58 and subject to a "watch and wait" regime of quarterly PSA tests, having been diagnosed with prostate cancer (mid-range gleason score) some 18 months ago. My PSA reading was eight at the time of biopsy and diagnosis, then declined to five over the course of the following year but has now risen to nine. I find this graph somewhat puzzling! As a result of the recent increase, I am to undergo a bone scan and pelvic MRI before a further meeting with my consultant in July. If the scans reveal anything untoward, I imagine that some sort of treatment will be recommended. However, what if the scans are "clean", so we can be fairly confident that the cancer has not spread? I believe I am right in saying that I am comparatively young to have prostate cancer. Is this an important factor in deciding whether, when and how to start intervening? I was successfully operated on for colon cancer in 2002 and am currently in the clear on that front. Name withheld, Cambridge

The regime that you describe is not now known as watchful waiting, but by any other term that implies that the doctor's have, as in this case, kept a very close eye on what is happening. When a PSA shows a regular and persistent rise it is important that the cause for it should be discovered, hence the reasons for bone scans, MRI etc. It is never possible to be certain that any patient, whatever their PSA, hasn't micrometastases elsewhere in the body. These are small groups of aberrant cells that have spread from the initial cancer, possibly before treatment started, remain dormant but have the potential to coalesce into a tumour if they become activated. If a secondary is found other treatment will be instituted.

The age at which men are developing prostate cancer is falling. Most of these cancers still start in the sixties and beyond but all urologists are seeing the occasional patient in their forties and many more in their fifties. Last year I met a man who had developed cancer of the prostate at the age of 36, but that is very unusual.

Is it possible to have this PCA 3 test here in UK and is it available on the NHS? Peter Sherman, Blackpool

Yes, there are five or six laboratories that are doing this test. For a variety of reasons most of the patients that I have known have had the test results analysed at the Doctor's Laboratory in Whitfield Street in London W1. The specimen that is analysed is collected by your urologist. I have no doubt that there are NHS labs that are doing this test, I should discuss this with your own doctor.

My husband was diagnosed with prostate cancer during a routine diabetic blood test. He had no symptoms, and if he had not been diabetic, he would not have known about it. The tests, hormone injections and radiotherapy were traumatic enough. What also concerns me is that if he had not been diabetic, it might not have been diagnosed for another five years, by which point, it may have been too late. Are there any plans for routine tests for men, such as women have for breast and cervical cancer? With diabetes, removing the prostate was not recommended, as the oncologist said there could be too many complications with the operation. So he opted for hormone injections and radiotherapy instead. Supposing the cancer returns, what options of treatment are there, and is it likely to return, or is that like looking into a crystal ball? Gill, Sussex

I agree with you completely. You and I as well as the American Cancer Society are in complete agreement that ideally all men over fifty, or over forty if there is a strong family history of cancer of the prostate, should have an annual PSA test carried out. It is a very simple blood test. Unfortunately this is not an ideal world and the PSA is not an ideal test. It gives a good indication whether further examinations or tests are needed, but it doesn't specifically diagnose cancer. It is, or should be, an effective way of ringing alarm bells that all is not well.

Related Links Dr Thomas Stuttaford answers your questions on thyroid problems Dr Thomas Stuttaford answers your questions on NSAIDs Dr Thomas Stuttaford answers your questions on home births The other tests you mention, including the biopsy, are of course not so pleasant as a PSA blood test and very occasionally have significant side effects. A raised PSA may lead to costly secondary testing and if every man who needed these additional tests had them it would, so I am told, bankrupt the NHS. What we need is a better test that would enable us to screen men as readily as women are now screened for cancer of the breast or cervix.

There is evidence that a diet rich in fruit and vegetables, especially tomatoes and berries, and low in fat, reduces the incidence of prostatic cancer. As you will have seen in recent news stories there is some doubt as to whether taking artificial vitamins may not have an adverse effect on the prostate incidence. These reports need further research before we all change tack and reject supplements. The prognosis in any case is hard to determine but the good news is that new methods of treatment are now beginning to appear.

My father is a fit and healthy 76 but found he had early stage prostate cancer ten years ago and had his prostate removed. He has been clear to date. His own father died from multiple causes, including prostate cancer. I am 50 and overweight but otherwise in reasonable health. I have had ‘wellbeing’ check-ups since my mid-thirties and have asked for an internal check in addition to the PSA check on each occasion. I assume that there is a significantly higher probability of me contracting prostate cancer given my family history? Being past 50 should I be ensuring I have an annual PSA check? Is there anything diet-wise I should be considering to reduce my chances of contracting it/slowing its development? I consciously drink plenty of cranberry juice and have always eaten plenty of fruit and vegetables, particularly broccoli. David Beale

In my opinion, and in the opinion of most British doctors, a family history in which both the father and grandfather died of prostatic cancer is certainly an indication for annual PSA testing and additional secondary tests if the PSA is above three or four (this figure will differ from urologist to urologist). Alarm bells should also ring if there is a sudden and persistent increase in a previously very low PSA. Keep eating the fruit and vegetables but above all keep your weight down. There is an association between being overweight and developing prostatic cancer, especially if the man is also fond of fatty food. A good exercise regime also reduces the likelihood of developing prostate cancer.

I recently turned 60 and went for my annual check up. I was informed by my urologist last week that my most current PSA reading was 7 – and he has advised I undergo biopsy to check for possible cancerous growth. I seem to have none of the other symptoms associated with BHP, other than urine flow that’s a little weaker than when I was younger. Is this something I should be seriously concerned about – does a PSA level this high dramatically increase the odds for cancer? Douglas Flannery

It is a golden rule in medicine not to wait for symptoms of prostatic problems such as getting up at night, a poor stream, bleeding in the urine or semen before having a PSA test carried out. The old axiom was that to wait for symptoms of prostatic cancer is to wait too long. If the PSA is raised additional secondary tests, including trans-rectal ultrasound and biopsy, are indicated. A PSA of seven at 60 is higher than would be expected and needs an explanation. There are many other possible reasons as well as cancer for a raised PSA, but nobody can take the risk of leaving a raised PSA uninvestigated.

I have a high PSA level and a friend who is a doctor has suggested taking a tomato lycopene supplement, based on a medical trial he read about recently. Can this really help? Joseph Guest

Cooked tomatoes, tomato sauces including ketchup as well as raw tomatoes are helping as are many of the highly coloured berries. Lycopene seems to be the flavonoid that is most efficacious. The question of vitamin supplements and cancer needs further research.

To read the original of this article Click Here

Comments @ TimesOnLine

Dear Sir

I have a PSA reading of 2.75 and have to get up once a night to go to the toilet, I also sometimes feel that i am going to dribble in my pants but manage to stop in time I have mentioned this to my doctor but although he says I have some symptoms he has not thought it desirable to have any further tests, should I accept his judgement or press for further tests I am 69 yrs old.

john rooney, Preston, england

Sir, with reference to symptons of prostate cancer, i have every one of the symptons mentioned in the article. However, i have been diagnosed with a " urethral stricture. " Not caused by any infection i hasten to add. I have undergone one " stretching " procedure, but now need surgery to correct the defect. Hopefully all will be ok after that. Fingers and everything else crossed..!

Kind regards, Scott Kerr, Daventry, Northamptonshire

I was diagnosed with Prostate Cancer in 2000 and prescribed Casodex until Radiotherapy 6 months later. My PSA for some time remained low but rose rapidly from 20 to 28 in 3 months, to 40 after a further 3 months when I was prescibed Casodex. Now a further 3 months later my PSA is less than I.

My Oncologist at my request suggested because of side effects that I stopped taking Casodex for 6 weeks before starting it again for another 6 weeks before a further PSA test.

I am 78 and my Oncologist thought that I should reach age 80 but what I really am interested in are the likely experiences I will get in the next 2 years or so.

Alfred Taylor, St Pierre du Bois, Guernsey CI

I must apologise when writing to you yesterday I forgot to mention that 3 months ago a CT scan showed up two metastases on my spine.

Alfred Taylor, St Pierre du Bois, Guernsey CI

"I recently read an article by you in which you stated that a person with damage to the Hippocampus lives only in the present. Is there any other explanation for my memory loss or am I correct in my self-diagnosis of a irreversible damaged Hippocampus which has brought on my current amnesia?"

Hippocampal atrophy is often seen in anxiety and depression patients and is probably caused by prolonged high levels of cortisol and other stress hormones.

Antidepressants reverse this by inducing neuro genesis, the growth of new neurons. Neuro genesis, rather than correction of a, probably non existent, "chemical imbalance" may be what produces the therapeutic effects of these drugs.

Ian Westmore, Andorra la Vella, Andorra

I would be interested in any comment on the issue of psa testing. I understand that nothing you eat or drink affects the psa level or reading - it not being a 'fasting.' blood test. However, I see regular comment that a psa level can vary from day to day - as much as 30% difference. If it is not food or drink, what is the reason for such possible fluctuations?

John, Brighton, England

I am 63 years old and have had annual psa tests for a number of years. For the past six years my psa readings have been between 1.0 and 1.3, my most recent test is now at 1.7. Should I be concerned? Also, what could be the reasons for the variations. My DRE has always been normal.

anthony sardo, windsor locks, ct

Dear Dr Stuttaford, Thank you for your comprehensive answer to my query. To update you, I saw my consultant again yesterday and was told that my PSA level has now fallen to 7.5 (from a high of 9.4 in mid-2006). Monitoring is continuing. Good luck with your own prostate.

Michael Hewitt, Ousden, Suffolk,

Disclaimer

E&OE - Errors & Omissions Excepted