Let's Review My Prostate Cancer = Part 2

Subject: Prostate Cancer Update #2 - January 17, 2008 - Ron Hoffman

This update has the following sections:
1. Introduction
2. Update Number 2 Executive Summary (this will bring you up to date)
3. Update Number 2 Details

Let me know what you think. I appreciate any and all comments. Feel free to forward to friends who may be facing similar decisions. Comments on my current course of action are welcome.

Thanks,

Ron

Ron Hoffman,
ronhoffman@yahoo.com


1. Introduction

Thanks to everyone who has asked about my prostate cancer status, and thanks to everyone who has sent an article or news of a friend who has gone through the decision process. If this is the first update you have seen, you may want to read the first blog (Part 1). Since a biopsy and diagnosis last August I have spent a lot of time looking into this very common disease for men.

2. Update # 2 Executive Summary

Since my first update I visited with three additional doctors and returned to one I had already seen. I have read or scanned a dozen books and read numerous internet blogs and websites. As I have indicated, there is almost too much information out there. And there is a wide range of choices of treatment and each one has strong advocates.

The last three doctors I visited were two surgeons and one radiation oncologist, then a revisit to Dr. Al Barqawi at the University of Colorado (See update # 1).

I continue to feel that there is a tendency to immediately treat any level of prostate cancer. This is driven by the patient’s concern that something needs to be done, and the doctor’s conservatism that the best way to “cure” the cancer is to remove the prostate or eradicate it with radiation, cold or high frequency. What used to be called watchful waiting was considered an alternative only for real old guys who were going to die of something else anyway (most literature mentions age 65 to 70 as the cutoff).

In connection with my visit to Dr. Barqawi, I had another PSA taken. My PSA had gone from 1 something to 2.1 and then to 2.7 which generated the initial suggestion of a biopsy. (These absolute PSA numbers are very low but if the PSA is changing at a rate that would cause it to double in 24 months, a biopsy is indicated [but some say not]). My latest PSA taken in December was back down to 1.97. In addition, I received a letter from the University of Colorado Second Opinion group (Dr. David Crawford). Their review of my biopsy indicated that one of the slides rated at Gleason 6 and 2% of the sample with cancer cells should not be considered as cancer in the opinion of the folks at the University of Colorado.

So, with a low PSA and only one small site of my prostate biopsied as cancerous, I am currently electing “Aggressive Surveillance” as my option - PSA taken every three months and an annual biopsy. If my PSA increases, I will again consider Dr. Barqawi’s Mapping approach (see cons below).

In my humble opinion, the side effects of prostate cancer “cures” are not worth the taking the risk of surgery - based on my PSA and biopsy results. The downside to this decision is that the cancer could be in more locations and could be more aggressive than I think. I did find a research report that indicated that less than 20% of Gleason 6 scores move to Gleason 7. Encouraging, but again not absolute.

So, it is wait and watch for now. This likely means deciding on a treatment at a later date, but it could mean no treatment (statistics are in the details below).

3. Update # 2 Details

This is more information on the doctors I visited since my first update, additional discussion of the mapping technique and Targeted Focal Therapy of Dr. Al Barqawi at the University of Colorado and more details on Active Surveillance.

I visited with Dr. Joel Gordon at the University of Pittsburgh in early December. He is very impressive. He does a full radical prostatectomy, but indicated that there is no need to store blood as he has never lost more than a tiny amount of blood during his surgeries. He was brought to the University by the President of UPMC after the President had prostate surgery with Dr. Gordon at Johns Hopkins. (Recommended by Jim Covert.) Based on my discussions with a friend, Greg Mikkelsen, about how his Doctor, Michael Koch, had indicated that open surgery allows for the ability to touch the nerve sites allowing for a better process to spare the nerves ---I felt that Dr. Gordon would be an excellent surgeon to consider. He did not favor waiting. His logic is that if you are going to eventually have a procedure done, why not do it now and not run the risk of more aggressive cancer later.

The next day, on my way back to Toledo, OH, I stopped in Sandusky OH. To visit with Dr. Phil Engeler, a radiation oncologist. He was very good, but did not give me any sense that radiation is something I should consider.

I visited again with Dr. Al Barqawi to discuss his mapping and Targeted Focal Therapy. At this point, my thinking was that I would participate in this process in March following my 10-K work at Dana Corporation in Toledo. As I discussed in Update #1, the mapping would determine if there are more areas of the prostate with cancer cells, and if the areas are not close to vital organs, Targeted Focal Therapy could be used to kill the cancerous areas without destroying the entire prostate. More discussion on this below - after a summary of my visit with Dr. Michael Cook at Indiana University in Indianapolis.

Dr. Barqawi was encouraging me to get the mapping done sooner rather than later. Janice asked if another PSA test would be helpful. Since it had been 5 months, Dr. Barqawi said yes. We kind of agreed that if the PSA had gone up, we would do the mapping sooner. If not, we could wait until March. The 1.97 result obviously met the criteria for deferring until March.

I also put in a call to a former associate at American Hospital Supply Corporation, Craig Davenport. Craig was CEO of Endocare, one of the leading Cryotherapy companies (he recently left to work for a Water Street Capital venture). Craig returned my call and said I have to see Dr. David Crawford and Dr. Al Barqawi. I told him, I had already seen them, and he indicated, you cannot be in better hands.

Last visit was to Indianapolis to see Dr. Michael Koch at Indiana University (and to visit with fraternity brother Keith Phelps and catch up on the 40 years since we had spent much time together). Dr. Koch was originally the first choice as a doctor and is probably the best choice as well, if I chose surgery. Gregg Mikkelsen had raved about Koch at the start of my research, and, based on Greg’s recommendation, I had scheduled the visit with Dr. Koch. Also, I had been impressed by Greg Mikkelsen’s explanation that the open surgery where touch was important was Dr. Koch method (but read on). Greg had convinced me that is an excellent choice for open surgery.

Interestingly and very positively, Dr. Koch has become a tremendous advocate of the da Vinci robotic surgery. He admitted to uncertainty about robotics initially, but after learning how the system works, he believes that the da Vinci robotic process is superior to open surgery. The magnification provided by the equipment, the sensitivity of the robotic arms and the minimally invasive nature of the surgery make it the absolute best choice for prostate surgery. He believes that many of the better surgeons will move to robotics. (David Crawford at Colorado has done so – although I am not sure he uses da Vinci – may just be a laparoscopic approach.

I asked Dr. Koch about the mapping technique used by Dr. Barqawi. He indicated that he knew of the technique and had been asked to participate in a discussion of the technique at an upcoming Oncology meeting. He made two comments that did lessen my interest in the mapping technique. The first was that he felt the large number of needles used for the mapping could scar the prostate and make surgery more difficult. The second point he made is that cryotherapy does not have any definitive studies for use for prostate cancer and is considered experimental. In spite of these concerns, I remain interested in Dr. Barqawi’s approach.

Johns Hopkins has an Aggressive Surveillance program. Here is their criteria for who should consider it:

Life expectancy – less than 15 years (older than 65) ----- This is the only one I fail
Palpability – non palpable (Stage T2 or lower) ----- OK (T1C)
Gleason (6 or less) -- [I have never heard of a five] ----- OK (Gleason 6 – 3+3)
Number of cancerous sites – 2 or less ----- OK (one)
Cancer at sites (less than 50%) ----- OK (less than 5%)
PSA density (0.1 or less) ----- OK (2.7 nl divided by 40 grams
equals .06 )
PSA - 4 or less (derived from density and 40 grams) ----- OK (1.97)
Free PSA 10% or greater ----- Not tested – next time
PSA Velocity – not a good indicator per several studies ----- With drop to 2 – my velocity
is low

Looks like the only problem is I am too young (which should be obvious to all of you).

There is a 30% chance that treatment will be needed in the future, and of that 30%, 25% will have incurable cancer (but still treatable). So there is an 7.5% chance (25% times 30%) of a more serious problem – but there is also a chance of recurrence if you proceed with aggressive treatment.

I am waiting for now.

Ron Hoffman
ronhoffman@yahoo.com