Johns Hopkins Health Alerts - Prostate Disorders

Urine-Based Prostate Cancer Screening Test Looks Promising

Thu, 24 Sep 2009 06:00:00 CDT

Today the diagnosis of prostate cancer typically begins with an abnormal prostate-specific antigen (PSA) test or perhaps a worrisome finding on a digital rectal exam (DRE). But because an elevated PSA level can be caused by benign prostatic hyperplasia (BPH), prostatitis, as well as prostate cancer, there is a need for a more specific screening test. Now a report in the journal Cancer Research (Volume 68, page 646) suggests that a urine-based prostate cancer test may be the answer.

An experimental prostate cancer screening test that is performed on a urine sample may be more reliable than the traditional PSA test. In a recent study, researchers evaluated a group of biomarkers found in urine for their ability to detect prostate cancer. (A biomarker is a substance found in the blood or other body fluids or tissues that can be used to detect or monitor a disease or to determine the effects of treatment.)

The researchers examined seven biomarkers in urine samples from men scheduled for a prostate biopsy or radical prostatectomy. Then they correlated the results of the procedures with the presence of the various biomarkers.

Used together, four of the substances -- GOLPH2, SPINK1, PCA3, and TMPRSS2:ERG -- identified which men had cancer. The group of four biomarkers outperformed PSA testing in its ability to specifically identify prostate cancer.

The main problem with PSA testing is that an elevated PSA level may also be caused by benign prostatic hyperplasia or prostatitis. This lack of specificity in PSA testing often leads to unnecessary biopsies. Although early findings are promising, more research is needed to improve the performance of urine tests for prostate cancer. For now, doctors will continue to rely on the current PSA test.

How Old Is Too Old For an Annual PSA Test?

Thu, 15 Oct 2009 06:00:00 CDT

If you are an elderly man, you may wonder if you should continue to have an annual PSA test to screen for prostate cancer. Here are the latest guidelines.

The U. S. Preventive Services Task Force recently recommended that doctors not screen men age 75 and older for prostate cancer. The panel weighed the potential benefits and harms of PSA testing in this population and concluded that the screening was more likely to have a negative impact on these men than a positive one.

The rationale: Prostate cancer is a slow-growing malignancy that may take 10 or more years to produce significant symptoms. Many elderly men will die of another condition before their prostate cancer becomes life threatening. Thus, an abnormal PSA test would lead to the pain and discomfort of a prostate biopsy and unnecessary worry if no cancer is found. If cancer is found and treated, the man will have to contend with side effects, such as sexual dysfunction and incontinence.

Other medical organizations recommend annual screening for men at average risk for prostate cancer beginning at age 50, but they do not address when screening is no longer necessary. And still others recommend screening for all men with a life expectancy of at least 10 years.

Bottom line advice: If you are age 75 or older, discuss the risks and benefits of PSA testing with your doctor. If you get tested and are diagnosed with a low-grade cancer, keep in mind that active surveillance is an option that allows you to be closely monitored but treated only if your disease progresses.

The Gleason Behind the Gleason Score

Thu, 03 Sep 2009 06:00:00 CDT

If you have had prostate cancer, you probably know that the Gleason score is the most important factor in predicting your current state of prostate cancer and its probable outcome. The score is based on tumor grade -- an indication of the tumor's aggressiveness. Tumor grade reflects how far the cancer cells deviate from normal, healthy cells, which are highly organized, with well-defined structures.

Cancer cells display various degrees of disorganization and distortion and could be likened to a Jackson Pollock painting. Cancers whose cells appear closest to normal are considered grade 1 and generally are the least aggressive; those with highly irregular, disorganized features are classified as grade 5 and generally are the most aggressive.

The Gleason score is derived by determining the two most prevalent organizational patterns in the tumor, assigning each a grade, and then adding the two numbers together. For example, if the most common pattern is grade 3 and the next most common pattern is grade 4, the Gleason score would be 3 + 4 = 7. Most pathologists do not recommend assigning Gleason scores below 5 based on needle biopsies because when the prostate is removed and the entire gland is evaluated, lower Gleason scores are almost always upgraded.

Most urologists would classify Gleason scores of 5 and 6 as low-grade tumors, a Gleason score of 7 as intermediate, and Gleason scores of 8, 9, and 10 as high grade, with the least favorable outlook.

The Gleason score was originally devised by Donald F. Gleason, M.D., a pathologist who created the unique and now ubiquitous scoring system in the 1960s based on his observations of prostate tissue taken from biopsy samples of more than 300 patients. The prostate tissue, when riddled with microscopic tumors, had a certain pattern when viewed under a microscope, and Dr. Gleason took note of that, assigning numbers to the various architectural patterns. He finally arrived at five representative pictures that were characteristic of all the patients. When reviewing background data on the patients, a strong correlation was found between their "Gleason score" and the patients' death rates.

By the late 1980s, Dr. Gleason’s system was used in all medical publications on prostate cancer, and is still in use today throughout the world. Your PSA test result, along with your Gleason score, predicts the likely outcome of prostate cancer and it's the gold standard test that will be used to diagnose more than 186,000 men this year with the disease.

BRCA-2 Gene Mutation and Prostate Cancer

Thu, 13 Aug 2009 06:00:00 CDT

A new study published in Clinical Cancer Research (Volume 14, page 2953) suggests that the BRCA-2 gene mutation increases a man’s prostate cancer risk.

Studies of identical and fraternal twins have found that prostate cancer has a stronger hereditary component than many other cancers, including breast and colon cancer. A number of genetic mutations are linked to prostate cancer. Some analyses suggest that mutations in HPC1 increase the risk of prostate cancer, but other studies have failed to find an association.

Now a study published in Clinical Cancer Research (Volume 14, page 2953) suggests that the BRCA-2 gene mutation increases a man’s prostate cancer risk.

Women who have mutations in the breast cancer predisposition genes BRCA-1 or BRCA-2 are known to be at a very high risk for breast and ovarian cancers. The fact that these gene mutations can also increase a man's risk of prostate cancer is less well known.

Researchers looked at families who had the BRCA mutations and who had at least one member who had developed prostate cancer. Men from families who carried the BRCA-2 gene mutation were 3.5 times more likely to develop prostate cancer than were men without the abnormality. Moreover, these men were at a higher risk for having an aggressive form of prostate cancer. In this study, the BRCA-1 mutation was not found to increase prostate cancer risk, but other investigators have reported such a link.

If you have a personal or family history of either mutation, you may have a higher-than-average risk of developing prostate cancer. Talk to your doctor about how often you should have your PSA level tested. Although no specific screening guidelines for men from hereditary breast-ovarian-cancer families have been promulgated, you may need to be seen at an earlier age or more frequently than men at average risk.

The Case for Active Surveillance

Thu, 11 Jun 2009 06:00:00 CDT

When a prostate biopsy indicates cancer, you might think you have to choose a treatment quickly. But usually there's no need to rush. Prostate cancer typically is a slow-growing malignancy, and most of the time men have months to consider their options. In this Health Alert, Johns Hopkins explains why active surveillance can be the right choice for some men.

The standard treatment options for prostate cancer include active surveillance, radical prostatectomy, radiation therapy, and hormone treatment. With active surveillance, a man opts to have no immediate treatment but undergoes close monitoring for cancer progression. Today this treatment approach is most often recommended for men with low-grade cancers that are believed to be small volume, especially older men whose cancers are unlikely to become life threatening during their remaining years of life.

The goal of active surveillance is to avoid unnecessary treatment in men whose cancer is unlikely to become life threatening over the next 10-15 years. Fewer than 10% of men who are candidates for surveillance take advantage of this approach.

Understandably, many men can't tolerate the anxiety and uncertainty of leaving a cancer growing -- even very slowly -- in their body. But with close monitoring, active surveillance can be a good choice for some. That's especially true for older men whose predicted life expectancy makes it unlikely that their cancer will progress in their remaining years of life.

The significant upside to active surveillance is that it allows a man to maintain an excellent quality of life without the side effects of radiation therapy or radical prostatectomy. But the approach requires close monitoring for signs of progression. This includes regular digital rectal exams (DREs), PSA tests, and a prostate biopsy each year or at some regular interval.

Not all prostate cancer specialists endorse surveillance. But research indicates that with careful monitoring, it can be a safe approach for many older men. Results of a 12-year study reported in the Journal of the American Medical Association showed only a 0.5% difference in the number of prostate cancer deaths between men treated with radiation therapy or radical prostatectomy and those whose cancers were managed with active surveillance.

Getting A Second Opinion

Thu, 02 Jul 2009 06:00:00 CDT

Prostate cancer is usually not an emergency. By taking your time, learning about your illness, and exploring your options, you're likely to make an informed decision that's right for you. And since doctors don't always agree on prostate cancer treatment, many men find it helpful to get a second opinion.

Although most people don't realize it, doctors don't always agree on the "best" treatment for early-stage prostate cancer. A recent study presented at the American Society for Clinical Oncology meeting found that men with early prostate cancer who consult only a urologist -- the doctor who performs radical prostatectomy -- are likely to choose that procedure. But men who see a urologist and a radiation oncologist are more likely to choose radiation therapy. This means it's wise to consult with a urologist and a radiation oncologist to get a clear understanding of your options. Health insurers generally pay for second opinions, and some even require them before certain procedures.

Getting a second opinion. You might be reluctant to suggest getting another opinion for fear of offending your doctor or thinking that he or she may not want to involve another physician. But many doctors welcome such discussions. If yours doesn't, strongly consider changing doctors.

Your primary care doctor and the urologist who performed your biopsy are the best sources for referrals. Request that, if possible, they suggest a colleague affiliated with a different hospital. Although this is not absolutely necessary, the practice is prudent because doctors who work at the same institution often share similar views and may not want to contradict one another. The American Medical Association (www.ama-assn.org) and the American Urological Association (www.urologyhealth.org) offer referral services.

Before your appointment. Check to be sure the doctor you consult is board-certified in the appropriate specialty. Ask your doctor's office to send a written summary and test results to the doctor you'll be consulting with. Call his or her office before your appointment to be sure the records have arrived as it will be impossible for your evaluation to take place without them.

At your consultation. Ask the doctor to explain why he or she is recommending a certain treatment, and take notes. Or bring a trusted family member or friend to help you remember the discussion, take notes, or ask questions you may have forgotten. Ask the consulting doctor to send a written report containing the recommendations to you and your referring physician.

Still not sure? If the specialists you see don't agree, schedule a consultation with a medical oncologist -- a cancer treatment specialist who does not perform radiation or surgery. Another option is to meet with a second urologist or radiation oncologist -- or both).

If you're having trouble making a decision, ask your primary care doctor -- or another specialist -- to help you sort through the options. Or, consider seeking an opinion at a nationally recognized cancer center, such as one that is affiliated with the National Comprehensive Cancer Network (www.nccn.org). It might also help to talk to men who have been treated for prostate cancer.

Why the PSA Velocity Test Is So Valuable

Thu, 30 Apr 2009 06:00:00 CDT

In a recent article posted on the Johns Hopkins Health Alerts website, Recent PSA Studies: What You Need To Know, H. Ballentine Carter, M.D., Director of Adult Urology at the Brady Urological Institute at Johns Hopkins wrote: "I think a lot of the over treatment we see has to do with using PSA as an absolute cutoff. I think PSA velocity, how fast the PSA moves over time, may be a better measure of the presence of lethal cancer." Here's some basic information about the PSA velocity test.

The PSA velocity measurement takes into account annual changes in PSA values, which rise more rapidly in men with prostate cancer than in men without the disease. A study from Johns Hopkins and the National Institute on Aging found that an increase in PSA level of more than 0.75 ng/mL per year was an early predictor of prostate cancer in men with PSA levels between 4 ng/mL and 10 ng/mL.

PSA velocity is especially helpful in detecting early cancer in men with mildly elevated PSA levels and a normal digital rectal exam. It is most useful in predicting the presence of cancer when changes in PSA are evaluated over at least one to two years. In a study reported in The New England Journal of Medicine, a rapid rise in PSA level (more than 2 ng/mL) in the year before prostate cancer diagnosis and surgical treatment predicted a higher likelihood that a man would die of his cancer over the next seven years.

Moreover, a Johns Hopkins study published in the Journal of the National Cancer Institute found that a man's PSA velocity 10-15 years before he was diagnosed with prostate cancer predicted his survival from the disease 25 years later. In the study, 92% of men with an earlier PSA velocity of 0.35 ng/mL or less per year had survived, compared with 54% of men whose PSA velocity was greater than 0.35 ng/mL.

For further information, see:

Recent PSA Studies: What You Need To Know

Using PSA Velocity to Predict Prostate Cancer Risk

Can TURP Spread Prostate Cancer?

Thu, 21 May 2009 06:00:00 CDT

The choice of treatment for prostate cancer -- active surveillance (also known as expectant management), surgery, radiation therapy, or hormone therapy -- depends on the clinical stage of the cancer and the age and general health of the individual. With increased use of PSA testing, some men will be diagnosed with small prostate cancers (which cannot be felt during a digital rectal exam but are confirmed by biopsy) that pose no immediate threat and may never need treatment. Here's a question from a reader who has chosen expectant management for his prostate cancer.

Q. I've chosen expectant management for my prostate cancer. Will having transurethral resection of the prostate (TURP) for nighttime urination spread the cancer cells within -- and possibly outside -- the prostate?

A. No strong evidence demonstrates that TURP in a man with prostate cancer leads to dissemination of the cancer. However, before you undergo TURP for nighttime urination (nocturia), your doctor should be sure that it is a result of prostate enlargement, also known as benign prostatic hyperplasia (BPH).

If nocturia is your only symptom, it is unlikely that treatment for BPH will improve the condition because the prostate is probably not the culprit. Increased urination at night has a variety of potential causes. In addition to BPH, these include use of certain medications (such as diuretics, lithium, phenytoin, and propoxyphene), urinary tract infections, diabetes, obstructive sleep apnea and other sleep disorders, and drinking too much fluid before bedtime, especially caffeine-containing beverages and alcohol.

Recent PSA Studies: What You Need To Know

Fri, 27 Mar 2009 06:00:00 CST

The recent contradictory studies of more than 240,000 men published in the New England Journal of Medicine (NEJM) about the effectiveness of using the prostate specific antigen (PSA) test for reducing death from prostate cancer left many men and physicians confused, upset, disappointed, and wondering what they should now do. One study reported that PSA saves lives, while the other noted no benefit whatsoever. To help our readers with this confusing data, we asked H. Ballentine Carter, M.D., Director of Adult Urology at the Brady Urological Institute at Johns Hopkins, to provides his thoughts. Here are Dr. Carter's remarks …

Granted, while both studies had their particular limitations, the PSA test has its own limitations. For example, an elevated PSA can be a tip-off to a lethal cancer, but it can also detect less aggressive cancer that may never cause harm. Since we don't yet have a definitive test that can tell the difference, and may not for many years, most prostate cancer experts believe that this cancer is now not only over diagnosed but also over treated.

Does the PSA test save lives -- according to the American Cancer Society, 28,000 men died from prostate cancer in 2008 -- or does it merely subject a large number of men with elevated PSAs to unnecessary surgery or radiation with side effects that can include urinary incontinence, erectile dysfunction, and irritative urinary and bowel symptoms? Doctors and patients alike have always wanted to know the answer for years, and they were hoping that these randomized trials would provide them. Unfortunately, they did not.

According to H. Ballentine Carter, M.D., Director of Adult Urology at the Brady Urological Institute at Johns Hopkins, the studies will not end the controversy surrounding the PSA test, a blood test that millions of men have been taking since it was first introduced in the late 1980s. It's currently estimated that 25 million PSA tests are performed annually in the United States."I am not sure that we learned a tremendous amount from the NEJM studies," admits Dr. Carter. "We already knew that we were over diagnosing and over treating this disease. Now we have numbers to document the extent of over treatment."

The studies published in the NEJM, from large randomized studies performed in North America and Europe, yielded contradictory results. An early analysis of the North American study of 77,000 men aged 55 to 74, which is still ongoing, showed no reduction in death from prostate cancer attributable to prostate cancer after seven to 10 years of follow-up.

However, the European study of 182,000 men aged 55 to 69, which is also ongoing, showed a 20% reduction in death among men who had PSA testing. For every life saved, however, 1,400 men need to be screened and 48 would need treatment following a positive PSA and digital rectal exam to result in one fewer death during a 10-year period.

Another way to look at it: 47 men who had a PSA test followed by surgery or radiation for their cancer may not have needed it, and many might go on to have urinary and erection complaints. In harming their quality of life while ostensibly protecting them from cancer, some men might say that this is too high price to pay for a disease that was not going to cause harm.

However, further follow-up could demonstrate a greater benefit of PSA screening and reduced harm as we learn more about the ability of PSA testing to prevent other outcomes, such as the development of metastatic disease and local progression of cancer that requires treatment. In addition, since prostate cancer takes a long time to progress, the 20% reduction in prostate cancer mortality found after 10 years could be higher with longer follow-up.

"PSA screening is certainly not perfect, but it is clearly saving some lives," says Dr. Carter. "If an individual is thinking about being tested, we now have some numbers to give him and he can make up his mind whether or not to be tested. If a man wants to continue to be tested, that's certainly reasonable. "

Once a man knows the risks and the trade-offs, he may or may not want to have a PSA test. "Americans are not like Europeans," concedes Dr. Carter. "We tend to be aggressive about wanting to know more. In spite of these new reports, I still think most men will still want to have the PSA test."

In light of these new studies, what should a man do? Says Dr. Carter: "I like what Dr. Michael J. Barry, M.D., medical director of the John D. Stoeckle Center for Primary Care, said in his NEJM editorial about the studies. He wrote, "The implications of the trade-offs reflected in these data, like beauty, will be in the eye of the beholder. Some well-informed clinicians and patients will still see these trade-offs as favorable; others will see them as unfavorable. As a result, a shared decision-making approach to PSA screening, as recommended by most guidelines, seems more appropriate than ever."

Bottom line: What the studies point out is that right now we still don't have a one-size-fits-all type test. While Dr. Carter believes that the value of the PSA test is still debated, until we have a better biomarker test that can differentiate inconsequential from lethal tumors, the PSA test needs to be used more judiciously. "I think a lot of the overtreatment we see has to do with using PSA as an absolute cutoff. I think PSA velocity, how fast the PSA moves over time, may be a better measure of the presence of lethal cancer.
"Doctors can get a lot more information if there is a PSA history, which is why I believe getting a baseline PSA at a younger age is a reasonable thing to do.," says Dr. Carter. "I recommend that all men should have an initial PSA test starting at age 40. A follow-up test should be given at age 45 and then again at age 50. Combining that information with the patient's age, size of the gland, and the free PSA test, should improve the accuracy of the PSA test. This will indicate their risk of developing prostate cancer.

"While not precise, it offers the best indication we have so far about the presence of cancer and what should be done," he says.

Can Vitamin D Prevent Prostate Cancer?

Thu, 19 Mar 2009 06:00:00 CST

If you thought vitamin D's main role was preventing rickets and strengthening bone, think again. Many researchers now believe that the "sunshine vitamin" may one day play a key role in preventing the growth of prostate cancer, and in killing rogue prostate cancer cells that have escaped into the body. The data are quite suggestive and vitamin D is a most promising area for prostate cancer research.

During the past decade, there's been a surge in research into the association between vitamin D and prostate cancer. Multiple studies have reported a link between sub-optimal levels of vitamin D and an increased risk of developing various cancers including prostate cancer, although not all studies have been confirmatory. While these findings are encouraging and could eventually lead to widespread screening for and treatment of vitamin D deficiencies, we still need a large, randomized, placebo-controlled trial to demonstrate whether vitamin D supplementation can actually prevent prostate cancer.

Vitamin D was first isolated by Adolf Windaus, who was awarded the Nobel Prize in 1928 for his work. Vitamin D is not actually a vitamin; it's a hormone. A vitamin is a substance you have to get from food. Vitamin D, however, is manufactured in the body -- the definition of a hormone. While researchers are still working to determine the effects of vitamin D on the prostate, here are some of the heart benefits of this vitamin:

Blood pressure regulation. While there is no direct evidence that vitamin D supplementation will lower blood pressure, people with high blood pressure generally have low blood levels of vitamin D.

Heart attack, stroke, heart failure reduction. A recent study in Circulation reported that events such as heart attacks, strokes, and heart failure were anywhere from 53% to 80% higher in people with low levels of vitamin D in their blood. That risk increased even more in people with high blood pressure.

Low blood levels of vitamin D may increase the risk of heart disease and stroke, especially for people with high blood pressure, according to researchers with the Framingham Heart Study. The scientists followed 1,739 men and women for more than five years and reported that participants with low blood levels of vitamin D were 62% more likely to develop cardiovascular disease than those with higher levels. For those with low vitamin D levels and high blood pressure, cardiovascular risk doubled.

Helps reduce inflammation. Researchers speculate that more vitamin D could lead to less inflammation in the arteries. Until recently, most researchers believed that heart disease was essentially a "plumbing" problem caused by an accumulation of hardened fat and cholesterol in the coronary arteries, known as plaque. However, an increasing body of evidence now shows that this accumulation of plaque is actually the result of chronic, low-grade inflammation in the coronary arteries. Researchers also believe that in the battle against heart disease, damping down this inflammation is nearly as important as lowering cholesterol.

Can the PSA Test Predict Cancer?

Thu, 26 Feb 2009 06:00:00 CST

A recent study suggests that a man's PSA level measured once when he is in his mid-40s to age 50 can predict whether he will develop prostate cancer up to 25 years later.

The prostate-specific antigen (PSA) test measures an enzyme produced almost exclusively by the glandular cells of the prostate. It is secreted during ejaculation into the prostatic ducts that empty into the urethra. PSA liquefies semen after ejaculation, promoting the release of sperm.

Normally, only very small amounts of PSA are present in the blood. But an abnormality of the prostate can disrupt the normal architecture of the gland and create an opening for PSA to pass into the bloodstream. Thus, high blood levels of PSA can indicate prostate problems, including cancer.

A blood test to measure levels of PSA was first approved by the U.S. Food and Drug Administration (FDA) in 1986 as a way to determine whether prostate cancer had been treated successfully and to monitor for its recurrence. Today, however, PSA tests are FDA approved for prostate cancer detection and are widely used to screen men for the disease.

Now a article published in the the Journal of Clinical Oncology (Volume 25, page 431) suggests that a man's PSA level in middle age may be predictive of prostate cancer years later.

The researchers examined the records and stored blood samples of more than 21,000 men who were age 50 or younger between 1974 and 1986. An average of 18 years later, nearly 500 of the men had developed prostate cancer. The investigators compared PSA data from 462 of these men with data from a group of 1,222 similar men who had not developed prostate cancer. They also looked at other potential prostate cancer risk factors, such as family history, diet, and exercise.

A man's total PSA level in middle age was the strongest predictor of whether he would develop prostate cancer. Using a PSA level of 0.5 ng/mL or lower for comparison, the researchers found that men whose PSA level was 0.51–1.0 ng/mL were 2.5 times more likely to develop prostate cancer. For those with PSA levels between 2 and 3 ng/mL (often considered to be in the "normal" range), the risk was more than 19 times higher.

Bottom line: The results suggest that PSA measurement in middle age might one day be used to determine which men need more intensive prostate cancer screening and which can be screened less frequently.

Research Links Obesity and Prostate Cancer Metastases

Thu, 15 Jan 2009 06:00:00 CST

If you or a loved one has prostate cancer and is obese with a body mass index of 30 or higher, results from these two studies provide added incentive for shedding excess weight.

Prostate Cancer Study 1: Prostate cancer is more likely to spread in men who are obese at diagnosis, according to findings from a study reported in the journal Cancer (Volume 109, page 1192).

The researchers monitored the outcomes of 752 men with local- or regional-stage prostate cancer. The men ranged in age from 40-64. Sixteen percent were current smokers, 14% had tumors with a Gleason score of 7 or higher, 63% were treated with radical prostatectomy alone, and 72% had PSA levels of 4.0 ng/mL or higher when diagnosed.

After an average of nearly 10 years, obese men (body mass index of 30 or higher) were more than three times as likely to have developed metastases and were more than twice as likely to have died of prostate cancer than their nonobese counterparts.

These findings held true even after the researchers took into account factors that could have increased the likelihood of prostate cancer spread and death. The poorer outcomes in obese men may be related to alterations in sex hormones, increases in cancer-promoting substances like leptin, or high levels of inflammatory molecules, all of which are associated with excess body fat.

Prostate Cancer Study 2: Prostate cancer treated by radiation therapy is more likely to recur in men who are obese. That's the conclusion of researchers who assessed the outcomes of 706 men with localized prostate cancer treated with radiotherapy.

The study participants' average age at diagnosis was 72, and they were monitored for nearly eight years. Normal weight was defined as a body mass index (BMI) of less than 25; overweight, 25-29.9; and obese, 30 or higher. About 28% of the men were normal weight; slightly more than half were overweight, and about 22% were obese. The obese men had been diagnosed at a younger age than the nonobese men, but they were similar in terms of disease stage, pretreatment PSA level, and Gleason score. None had received androgen-deprivation therapy.

The results showed that the average time to biochemical recurrence (relapse of prostate cancer detected by a rising PSA level) was 93 months for normal-weight men, 88 months for overweight men, and 84 months for obese men. It's too early to say that losing weight can lower your risk of a relapse of prostate cancer if you're obese, but these results show that obesity is a major health concern that affects more than your heart. Data was reported in the British Journal of Urology International (Volume 100, page 315).

Dietary Changes for Metastatic Prostate Cancer

Thu, 23 Oct 2008 06:00:00 CDT

The effects of diet and lifestyle on the progression of prostate cancer are difficult to study and research results are often conflicting. Nonetheless, many men who face prostate cancer look to a healthy low-fat diet with a high intake of vegetables as a way to keep their cancer from spreading. This question and answer on diet and prostate cancer comes from a recent issue of the Johns Hopkins Prostate Bulletin.

Q. I am 59 and was diagnosed with prostate cancer three years ago. I had a PSA of 8 ng/ml and a Gleason score of 7. I had proton beam radiation to eliminate the prostate cancer, but within 18 months my PSA started to rise.

I radically changed my diet after getting that horrible news and have now eliminated all caffeine and high-fat foods. My PSA dropped within a few months, and a recent bone scan has shown a definite tumor reduction. I want to believe that nutrition can play a powerful role in keeping the prostate cancer from spreading, but am I just deluding myself? Lake Hill, NY

Dr. Mostwin answers: Consider the inspiring story of Michael Milken. He was diagnosed with prostate cancer in 1993 with evidence of spread to the lymph nodes. He devoted himself to researching lifestyle modifications that might help him beat the prostate cancer, and through extreme dietary changes and personal discipline, he continues to do well, remain active, and champion the cause for improved awareness and research into prostate cancer to help others.

You can learn more about his disease-fighting diet by looking at The Taste for Living Cookbook: Mike Milken's Favorite Recipes for Fighting Cancer, which he wrote with chef Beth Ginsburg (published by Milken's foundation, CaP CURE, in 1998; ISBN 0966080564).

Underscoring the Importance of Experience

Thu, 13 Nov 2008 06:00:00 CST

According to a recent study, the risk of a prostate cancer recurrence after radical prostatectomy appears to depend in large part on how many procedures the surgeon has performed. The take-home message: experience counts.

Radical prostatectomy was developed at Johns Hopkins at the beginning of the 20th century. The operation was not popular at first because of the high rate of erectile dysfunction and urinary incontinence associated with the prostate surgery procedure.

But in the early 1980s, Johns Hopkins urologist Patrick Walsh, M.D., developed a new approach to the prostate surgery operation. He devised a "road map" that allows surgeons to remove the prostate with less risk of damaging the nerves that are essential for erections and urinary control. This "nerve-sparing" prostate technique has reduced the risk of severe incontinence to 1-3% and the risk of mild incontinence to around 10%.

The risk of erectile dysfunction varies according to a man's age and the surgeon's skill. One group of researchers reported that nerve-sparing prostate surgery achieved successful recovery of erections in 68% of patients. Dr. Walsh has performed the prostate procedure on more than 2,000 men with early prostate cancer, preserving erectile function in 90% of men in their 40s, 75% of those in their 50s, and 60% of those in their 60s.

The importance of surgeon's experience as it relates to prostate cancer outcome is underscored by the results of a study reported in the Journal of the National Cancer Institute (volume 99, page 1171).

Researchers analyzed the outcomes of 7,765 radical prostatectomies performed by 72 surgeons between January 1987 and December 2003 at four major academic medical centers. "Biochemical" recurrence was defined as a postsurgery PSA level greater than 0.4 ng/mL followed by a subsequent higher PSA level. The analysis took into account patient and tumor characteristics, such as pre-operative PSA level and Gleason grade. The men's PSA levels were measured every three to four months in the first year after surgery, twice in the second year, and annually during the following years.

The researchers found that surgical outcomes improved along with the number of radical prostatectomies a surgeon had performed, leveling off only after about 250 surgeries. The five-year probability of experiencing a recurrence of prostate cancer was 18% for surgeons who had performed only 10 operations compared with 11% for surgeons who had performed at least 250 surgeries.

Bottom line on prostate cancer surgery: The results suggest that you can improve your odds of a successful outcome from radical prostatectomy by taking time to find a surgeon with extensive experience.

Understanding the TNM Prostate Cancer Staging System

Thu, 02 Oct 2008 06:00:00 CDT

Determining the extent of prostate cancer is important for predicting the course of the disease and in choosing the best treatment. The TNM (tumor, nodes, metastasis) staging system is used to describe a cancer's clinical stage, or how far it has spread. This Health Alert provides an explanation of this important prostate cancer staging system.

The TNM system assigns a T number (T1 to T4) to describe the extent of the tumor as felt during a digital rectal exam (DRE). The N number (N0 to N1) indicates whether the cancer has spread to any lymph nodes, and the M number (M0 to M1) indicates the presence or absence of metastasis (spread to distant sites). The T and M designations are divided into subcategories (designated a, b, and c) that provide further detail on the extent of the cancer.

T1a: Tumor found incidentally during surgery for benign prostatic hyperplasia (BPH) and is present in less than 5% of removed tissue

T1b: Tumor found incidentally during BPH surgery but involves more than 5% of removed tissue

T1c: Tumor found during needle biopsy for elevated PSA

T2: Tumor can be felt during DRE but is believed to be confined to the gland

T2a: Tumor involves one half or less of one side of the prostate

T2b: Tumor involves more than one half of one side but not both sides

T2c: Tumor involves both sides of the prostate

T3: Tumor extends through the prostate capsule and may involve the seminal vesicles

T3a: Tumor extends through the capsule but does not involve the seminal vesicles

T3b: Tumor has spread to the seminal vesicles

T4: Tumor has invaded adjacent structures (other than the seminal vesicles), such as the bladder neck, rectum, or pelvic wall

NO: Cancer has not spread to any lymph nodes

N1: Cancer has spread to one or more regional lymph nodes (nodes in the pelvic region)

MO: No distant metastasis

M1: Distant metastasis

M1a: Cancer has spread to distant lymph nodes

M1b: Cancer has spread to the bones

M1c: Cancer has spread to other organs, with or without bone involvement

Propecia and Your PSA

Thu, 05 Feb 2009 06:00:00 CST

If you're a man who takes the hair-growth drug Propecia, you should let your doctor know before you have your next PSA test, as it could affect the accuracy of the results.

The prostate-specific antigen (PSA) test measures an enzyme produced almost exclusively by the glandular cells of the prostate. It is secreted during ejaculation into the prostatic ducts that empty into the urethra. PSA liquefies semen after ejaculation, promoting the release of sperm.

Normally, only very small amounts of PSA are present in the blood. But an abnormality of the prostate can disrupt the normal architecture of the gland and create an opening for PSA to pass into the bloodstream. Thus, high blood levels of PSA can indicate prostate problems, including cancer.

A blood test to measure levels of PSA was first approved by the U.S. Food and Drug Administration (FDA) in 1986 as a way to determine whether prostate cancer had been treated successfully and to monitor for its recurrence. Today, however, PSA tests are FDA approved for prostate cancer detection and are widely used to screen men for the disease.

Now research suggests that the hair-growth medication Propecia (finasteride) significantly lowers a man's PSA level, producing misleading results and potentially masking the presence of prostate cancer.

Propecia is the same medication as Proscar, which is used to control benign prostatic hyperplasia (BPH). The difference is the dosage -- 5 mg per day for Proscar vs. 1 mg for Propecia. Proscar is known to artificially lower PSA levels by about half, and doctors interpreting PSA results in these men compensate by doubling the PSA value. But Propecia's impact on PSA level has not been formally studied until now.

The researchers in the study which was reported in the journal Lancet Oncology (Volume 8, page 21) assigned 355 men age 40-60 to take either Propecia or a placebo (inactive pill) for 48 weeks. For analysis purposes, the men were grouped by age: 40-49 and 50-60. By the end of the study period, PSA levels among men in the younger group had dropped by an average of 40%; in the older group, PSA declined by an average of 50%. Among men taking the placebo, the PSA levels of the younger men had not changed, and the levels of the older men had risen by an average of 13%.

Bottom Line: If you use Propecia, be sure to let your physician know so that your PSA results can be adjusted accordingly.

HIFU: Testing a Novel Prostate Cancer Procedure

Thu, 21 Aug 2008 06:00:00 CDT

High-intensity focused ultrasound, or HIFU (pronounced HIGH-foo), is a promising technology for noninvasive tumor ablation that heats cancerous prostate tumors to near-boiling temperatures. Its potential clinical impact is indeed significant. But given the lack of long-term clinical data, Johns Hopkins advises caution.

Image-guided HIFU procedures could permit the ablation of tumors (not only in the prostate, but also in the liver and lung) without the need for surgery or even an incision. This form of treatment has the potential to minimize side effects -- incontinence and erectile dysfunction -- and improve quality of life for prostate cancer patients while offering a rapid recovery and return to daily activities.

“HIFU is the next frontier in prostate treatment,” said John C. Rewcastle, Ph.D., Adjunct Assistant Professor of Radiology at The University of Calgary and medical director of EDAP, a manufacturer of Ablatherm, a HIFU device. Dr. Rewcastle is directing ongoing HIFU prostate cancer studies in Europe and the United States. “HIFU has the ability to answer the over-diagnosis and over-treatment questions that now surround prostate cancer treatment.”

There are currently two HIFU devices for the treatment of prostate cancer: Sonablate (Focus Surgery, Inc., Indianapolis, Indiana) and Ablatherm (EDAP, Lyon, France). Although both devices are approved in Europe, Mexico, Canada, and the Far East, they are available in the U.S. for prostate cancer treatment only as part of ongoing Phase II/III trials to assess their safety and efficacy.

Cancer cure rates are the primary consideration in any prostate therapy, whether it entails surgery, radiation, or high frequency sound waves. Since HIFU is such a new therapy for prostate cancer, and the pool of treated patients is relatively small, there is not yet a rich source of data to draw upon.

A five-year follow-up study from urologists at the University of Regensburg in Germany was published in 2004 in the journal Urology (“High-Intensity Focused Ultrasound for the Treatment of Localized Prostate Cancer: 5-year Experience”). From the pool of 137 patients, the doctors reported that 93% had negative biopsies following HIFU therapy for prostate cancer; 87% of all patients had constant PSA levels of less than 1 ng/ml; and only two patients had PSA levels that surpassed 4 ng/ml.

The jury's still out … While HIFU is a technology with considerable promise, many doctors agree with Dr. Robertson of Duke University who remarked, "Although many centers in Europe have used it and achieve varying results with many patients, there have not been a lot of scientific publications. We are in the dark about how effective this treatment is long term."

H. Ballentine Carter, M.D., Professor of Urology at Johns Hopkins, has performed more than 3,000 radical prostatectomies. His two words of advice for men contemplating HIFU therapy for prostate cancer: “Buyer, beware!”

Clinical Trials Q & A

Thu, 31 Jul 2008 06:00:00 CDT

In this "Ask the Doctor" column from the Prostate Disorders White Paper, Johns Hopkins Professor Dr. H. Ballentine Carter answers a question that's on the minds of many men diagnosed with early-state prostate cancer: "Are there any meaningful clinical trials for prostate cancer patients who are not at an advanced stage?"

At Johns Hopkins we are carefully monitoring men with small volume prostate cancer tumors in an expectant management program. In addition, a number of clinical trials exploring adjunctive or complementary therapies for early prostate cancer are either planned or under way.

Some of the prostate cancer treatments being studied are high intensity focused ultrasound to destroy cancerous tissue; everolimus (an agent that blocks some of the enzymes needed for cell growth) given before prostate cancer surgery; granulocyte-macrophage-colony-stimulating factor (GM-CSF) given before prostate cancer surgery to help the body build an effective immune response to kill stray tumor cells; and pomegranate juice given to men with rising PSA levels after prostate cancer surgery or radiation therapy.

Clinical trials have strict criteria for participation, and some may be demanding in terms of time or travel. Ask your urologist or surgeon about clinical trials that might be appropriate for your medical situation and make sure you understand the pros and cons of participating in a trial.

You can view the types of prostate cancer trials planned or under way at www.clinicaltrials.gov (type in “prostate cancer, early stage” in the “Search Clinical Trials” box).

Multivitamins and Prostate Cancer

Thu, 10 Jul 2008 06:00:00 CDT

The underlying cause of prostate cancer is unknown. As with other cancers, however, multiple events over a period of many years are probably necessary to produce a cancerous change in a prostate cell. A recent study links overuse of multivitamin supplements with the risk of fatal prostate cancer.

The development of cancer is broadly viewed as a two-step process. The first step is initiation, when the cell is exposed to substances (such as a chemical), agents (such as a virus), or forces (such as radiation) that cause an alteration (mutation) in the genetic machinery of the cell. The second step is promotion, in which other chemicals, hormones, or diet and lifestyle patterns stimulate the growth and reproduction of the abnormal cell. A promoter does not set the process in motion, but it creates an environment favorable for the runaway growth that causes a cancerous tumor to form and progress.

Now a study reported in the Journal of the National Cancer Institute (Volume 99, page 754) sheds light on a possible new promoter: excessive use of multivitamins.

The study analyzed information on multivitamin and supplement use in nearly 300,000 men enrolled in the National Institutes of Health-AARP Diet and Health Study. Researchers gathered information on diet and use of multivitamins and other supplements.

All men were cancer free at enrollment. But over the next five years 10,241 developed prostate cancer, 8,765 had localized disease (cancer that has not spread beyond the gland), and 1,476 had advanced cancer. Six years later, 179 men had died of their cancer.

No link between multivitamin use and the development of localized prostate cancer was seen. But men who took multivitamins more than seven times per week had double the risk of fatal prostate cancer. The risk was highest among men with a family history of prostate cancer and those who also took individual supplements of selenium, zinc, or beta-carotene.

The bottom line: One multivitamin a day isn’t a problem, but don’t take more than that, and be cautious about adding individual supplements since they may provide the intended micronutrient in "macro” amounts.

Refining What PSA Levels Mean

Thu, 19 Jun 2008 06:00:00 CDT

In this excerpt from a recent issue of Health After 50, H. Ballentine Carter, M.D., Professor of Medicine at the Johns Hopkins Hospital, discusses current trends in PSA testing.

Since the prostate specific antigen (PSA) test became widely used in the 1990s, prostate cancer deaths have dropped dramatically. Today one of the biggest problems with PSA testing is that it detects many cancers that are not life threatening and would never have been diagnosed or treated otherwise, especially among older men.

Q. How does PSA testing result in overdiagnosis?

Dr. Carter: PSA levels are most often elevated for reasons other than cancer, such as prostatic enlargement (benign prostatic hyperplasia -- BPH) or prostatic inflammation, which are common among aging men. In addition, many men with these conditions also have small prostate cancers that are also common with age but usually do not progress.

The PSA test cannot differentiate between dangerous cancer and benign conditions, so when biopsies are based on elevated PSA test results, prostate cancers are often found serendipitously; many of these would not have been found otherwise. This over diagnosis of prostate cancer has been estimated to occur in 30–50% of men between ages 55 and 80 years. Over 85% of prostate cancers detected are treated when diagnosed. Thus, over treatment of cancers that would not have caused harm is a byproduct of screening.

The extent to which PSA testing for the early diagnosis of prostate cancer results in more benefit (reduction of prostate cancer deaths) versus harm (detection and treatment of prostate cancers that would not have caused harm) is hotly debated. Nevertheless, physicians and patients prefer the risk of unnecessary treatment to missing a potentially lethal cancer. The solution to the dilemma is a test that can differentiate between life- threatening and indolent prostate cancer before a biopsy takes place.

Q. In the meantime, how are doctors trying to reduce the number of needle biopsies and over diagnosis?

Dr. Carter: Currently, annual PSA testing beginning at age 50 is recommended, but newer guidelines will stress the need for a baseline PSA test at age 40, another one at 45, and then an annual or biennial PSA test beginning at age 50 depending on the PSA level. By starting to accumulate a PSA history at age 40, a man will have measurements to compare with levels obtained in his 50s in order to determine the rate his PSA changed -- his PSA velocity—a useful measure of the presence of a life-threatening cancer.

PSA levels vary a lot over the short term (6 months). It is important to have a PSA history of more than two years to evaluate PSA velocity accurately. If PSA velocity is consistently above 0.4 ng/mL per year in a man with a PSA level below 4.0 ng/mL, prostate cancer should be suspected and a biopsy considered. In men with PSA levels between 4 and 10 ng/mL, a PSA velocity of 0.75 ng/mL per year suggests the presence of prostate cancer.

PSA Questions Answered

Thu, 04 Dec 2008 06:00:00 CST

Is there a reliable PSA cutoff? H. Ballentine Carter, M.D., Professor of Medicine at the Johns Hopkins Hospital, answers this question and others in this excerpt from the Johns Hopkins Health After 50 newsletter.

Q. Is there a reliable PSA cutoff?

Dr. Carter: In the past, doctors relied more heavily on a standard PSA cutoff of 4.0 ng/mL to determine when a biopsy should be done, but no absolute cutoff point is accurate for everyone. Other risk factors we need to know about include a history of prostate cancer on both parents’ sides and race -- black men are at much higher risk for developing prostate cancer, particularly life-threatening prostate cancer. Age is also very important. A younger man might be at much higher risk for harboring cancer than an older man with the same PSA level. Younger men are less likely to have a PSA ele- vation due to prostate enlargement.

Q. Are you ever old enough to stop getting a PSA test?

Dr. Carter: This is a very difficult question that no one has adequately addressed. If a man is over 70 and in poor health owing to another illness or condition, a PSA test may not be necessary since it’s unlikely that he will die of prostate cancer. On the other hand, it may make sense for a healthy 70-year-old to continue with PSA testing.

If a man has maintained a very low PSA throughout his life (e.g., below 3.0 ng/mL), he may not need testing after age 75.

Q. What other tests besides PSA are currently under exploration?

Dr. Carter: Robert Getzenberg,M.D., Director of Research at the Brady Urologicial Institute at Johns Hopkins, discovered a protein (early prostate cancer antigen, or EPCA) that is present in the blood in higher amounts in men with prostate cancer than in men without it. EPCA appears to be more prostate-cancer specific than PSA, and the test could reduce unnecessary biopsies and, possibly, over diagnosis and over treatment of prostate cancer. More work is needed to determine the value of this test for early detection.

[For more information on EPCA-2, see our article A Better Blood Test For Prostate Cancer

Talking with the Pathologist

Thu, 08 May 2008 06:00:00 CDT

In this Q and A from the Prostate Bulletin, Dr. Jonathan Epstein, The Reinhard Professor of Urologic Pathology at Johns Hopkins, talks about the intricacies of prostate biopsy.

Q. Is it possible that a 12-core biopsy can miss a prostate cancer?

Dr. Epstein. Most of the time, good sampling of the prostate means taking 10, 12, or 14 or more cores. Even so, there is potentially a high likelihood of biopsy missing cancer. This depends on where the cancer is located, how big it is, and how the biopsy is performed.

You must understand that it is not just the number of cores that is important, but where the cores are sampled within the prostate. The urologist needs to perform a good sampling of the prostate, taking in the peripheral zone (located next to the rectum, contains most of the glands in the prostate, and is the main site where cancer develops), and making sure not to go too deeply into the gland and overshoot the target areas. That can greatly minimize the risk of missing a cancer. Even so, biopsies are still not perfect, and about 15 to 20 percent of biopsies still miss the cancer.

Q. If the biopsy comes back clean but you still suspect cancer, when should a biopsy be performed again?

Dr. Epstein. This will all depend on how suspicious the urologist is before the biopsy is performed. For example, if there is a very suspicious nodule on rectal exam and the biopsy comes back negative, a repeat biopsy is generally recommended. Then, too, if the PSA is over 10 ng/ml and the biopsy comes back benign, you want to do a repeat biopsy. If there is a rapid rise in PSA shortly after the original biopsy comes back benign, this would also warrant a repeat biopsy.

If there is something very suspicious clinically and the first biopsy is negative, I recommend waiting a few months, but no more than 90 days, before performing the next biopsy. This allows the patient’s memory of the discomfort caused by the biopsy to fade before doing the repeat test.

Q. How difficult is it render a definitive diagnosis after reviewing a prostate biopsy slide?

Dr. Epstein. Looking at and diagnosing limited prostate cancer on biopsy is one of the most difficult diagnoses in pathology, for several reasons. For starters, prostate cancer is often very tiny on a needle biopsy. While some other cancers in the body are obvious in terms of their malignancy and how they appear under the microscope, the findings of malignant prostate cancer tend to be extremely subtle. Put these factors together and you can end up with problems interpreting the slides, with both under-diagnosis and over-diagnosis as possible outcomes.

Understanding the Risk Factors

Thu, 17 Apr 2008 06:00:00 CDT

In this Health Alert from the Prostate Bulletin, Dr. Jacek Mostwin and colleagues discuss five important risk factors for prostate cancer.

Age, race, and family history are important risk factors for prostate cancer. Diet and lifestyle factors may also influence whether a man develops the disease. No clear association has been found between the development of prostate cancer and smoking, vasectomy, the presence of benign prostatic hyperplasia (BPH), or regular alcohol intake (although binge drinking may increase the risk). Increasing evidence suggests that fat intake, physical inactivity, or being overweight may influence the development or progression of prostate cancer.

Age
As a man ages, his risk of developing prostate cancer increases dramatically. This age-related increase is greater for prostate cancer than for any other type of cancer. The average age at the time of diagnosis is between 65 and 70, and the average age of death is between 77 and 80.

Race
The incidence of prostate cancer in the United States varies by race. The rate for white men is 101 per 100,000 each year. Black men are at higher risk (137 per 100,000), and Asian Americans are at the lowest risk (20 to 47 per 100,000).

Family History
Studies of identical and fraternal twins show that prostate cancer has a stronger hereditary component than many other cancers, including breast and colon cancer. Having one first-degree relative (a brother or father) with prostate cancer doubles the risk of developing the disease; having a second-degree relative (an uncle or grandfather) with prostate cancer confers only a small increase in risk.

A number of genetic mutations are linked to prostate cancer. The best studied of these mutations are in a region of chromosome 1 known as HPC1. HPC1 may be involved in protecting against prostate inflammation. Some analyses have suggested that mutations in HPC1 increase the risk of prostate cancer, but other studies have failed to find an association. Other genes involved in how the body handles male hormones (androgens), its reaction to inflammation or infection, and its ability to process certain types of fat may also be important.

Although genes can influence a man’s risk of developing prostate cancer, other factors are also at work. The likelihood that identical twins (who share all genetic information) will both develop prostate cancer is 19% to 27%. This suggests that lifestyle choices can modify the effects of the genetic cards that a person is dealt at birth.

Environmental Factors
Much effort has been devoted to searching for environmental factors that might serve as promoters for prostate cancer. The incidence of microscopic prostate cancer (cancers too small to be seen except under a microscope) is similar among men in the United States and in all other countries that have been examined. However, the mortality rates from prostate cancer differ from one country to another and even within different regions of the United States. These differences suggest that environmental factors (such as diet, lifestyle, or exposure to certain substances or forces) influence prostate cancer’s progression from microscopic tumors to clinically significant ones.

Dietary fat
Most studies examining the relationship between dietary fat and prostate cancer have found that a higher fat intake (especially animal fat) is associated with an increased incidence of prostate cancer. Fat makes up 30% to 40% of the calories in the American diet, compared with 15% in Japan. This difference in fat consumption may help explain the much lower death rate from prostate cancer in Japan, as well as the great variability in prostate cancer mortality rates around the world. It is also possible that people who consume large amounts of high-fat foods are less likely to eat healthful foods that may protect against cancer.

Dr. Mostwin Answers Readers' Questions

Thu, 27 Mar 2008 06:00:00 CST

In this Health Alert, Dr. Jacek L. Mostwin, a urological surgeon at Johns Hopkins, answers readers’ questions about prostate cancer treatment. The questions come from a recent issue of the Johns Hopkins Prostate Bulletin.

Prostate Cancer Question 1: RADIATION OR SURGERY

Q. Well, I am now officially a member of the “prostate cancer club.” My doctor called me yesterday with my biopsy results: Gleason 7 and PSA of 6.8 ng/ml. I am 63 years old and will do something soon to get rid of the prostate cancer. I have been divorced for two years now and still have an active dating life, which is one of the reasons I have been considering radiation therapy as my treatment. Losing my erection to prostate surgery would be too great a sacrifice for me right now. My best friend, who had a radical prostatectomy three years ago (and now successfully uses Viagra), tells me that with radiation you can never be sure all the cancer has been killed off, so I should go with the surgery? Annapolis, MD

A. With respect to surgery, it is fair to say that if you can be cured, you will be cured. By that I mean, if the cancer has not yet spread out of the prostate, and the gland is removed before that possibility ever develops, you will never have the disease again. It is not at all clear that radiation therapy can offer that outcome. With respect to potency, the nerve bundles are located within millimeters of the prostatic capsule. During surgery, one can separate them and still remove all cancer. It is more difficult for radiation to preserve these nerves while still applying the high energy to the prostatic tissues only millimeters away.

Prostate Cancer Question 2: POSITIVE MARGIN REMAINING

Q. I love the Prostate Bulletin! Thank you! On July 2, 2007, I had my prostate removed by a surgeon using a Da Vinci robot. Unfortunately, the doctor left behind some of my prostate -- a positive margin on the left side. The pathology report showed: Adenocarcinoma (conventional, not otherwise specified), a Gleason of 3+4, with a stage of nT2c, and 20% of prostatic tissue involved. My biopsies had shown no prostate cancer on that left side. In 2004, I had a PSA of 1.72 ng/ml; in 2006, it was 1.92. Just prior to the surgery, my PSA was up to 2.0. I am thinking of coming to Johns Hopkins to have that remaining positive margin tissue removed by means of regular open surgery. Do you know of any similar cases (i.e., having an open surgery done to correct mistakes made by a robotic surgery)? Via E-mail

A. Whether the prostate surgery is performed by an open, robotic, or laparoscopic technique, the interior scarring will be the same. In general, it’s very rare to operate on the prostate a second time to remove additional prostatic tissue. We have done it once after an obviously incomplete prostatectomy was performed on a very young patient, but the operation was profoundly difficult, as scarring from the first operation made the field almost impossible to work in. If only a minute margin is suspected, it would be inadvisable to re-operate. It’s unlikely that the tissue would ever be found, and a lot of damage could be done.

Your situation is really too complicated to address here, but one can make a few general comments. If the positive margin is due to a small amount of tissue and the PSA falls to an undetectable level after prostate surgery, there may be no need to treat right now, although a practitioner might advise supplemental radiation therapy even before waiting to see if the PSA goes up. If, on the other hand, a large piece of the prostate was left behind, there were grossly positive margins, and the PSA was still elevated after surgery, then one could make a case for additional radiation therapy right away.

Is Watchful Waiting for Prostate Cancer Safe?

Fri, 13 Jun 2008 06:00:00 CDT

Is watchful waiting (close monitoring rather than immediate surgery) for low-grade prostate cancer a safe alternative? New research from the Journal of the National Cancer Institute offers guidance.

Today watchful waiting for prostate cancer is most often recommended for men with low-grade prostate cancer that is believed to be small volume, especially older men whose prostate cancer is unlikely to become life threatening during their remaining years of life.

Men who choose watchful waiting must see their doctor regularly and undergo testing to determine whether the cancer is progressing. Recommendations on the frequency of visits and the tests conducted each time vary from doctor to doctor. Johns Hopkins recommends the following guidelines for men age 75 and younger who are in otherwise good health: PSA testing and a digital rectal exam twice a year and transrectal ultrasound and prostate biopsy once a year. The recommendations for PSA testing and digital rectal exams remain the same after age 75, but yearly ultrasound and prostate biopsy are no longer routinely performed.

Now new research reported in the Journal of the National Cancer Institute (Volume 98, page 355) indicates the delayed treatment is indeed safe for low-grade prostate cancers. Johns Hopkins researchers have provided solid evidence from a comparative study that delaying prostate cancer surgery for 26 months or more does not compromise curability. They assessed the outcomes of men thought to have small-volume low-grade cancers: 38 men who did choose expectant management as well as 150 men who had surgery immediately, within about three months of diagnosis.

Men in the expectant-management group had digital rectal exams, measurements of total and free PSA twice a year, and a yearly prostate biopsy. An ominous prostate biopsy finding or the patient’s request for treatment triggered a move to surgery.

The risk of prostate cancer recurrence (based on the pathology findings at surgery) after at least two years proved similar in the two groups, the researchers report. Their conclusion: For a low-risk prostate cancer patient, opting to watch and wait is not, in fact, a risky decision.

About Your Prostate

Fri, 11 Jan 2008 06:53:13 CST

About Your Prostate

The prostate is a walnut-sized gland located just below the bladder in men. It surrounds the urethra, the tube that carries urine away from the bladder. The prostate keeps urine and semen flowing in the proper direction, and it also produces a component of semen called prostatic fluid.

When a man reaches middle age and beyond, the inner portion of the prostate begins to enlarge and may put pressure on the urethra. This enlarged prostate condition is called benign prostatic hyperplasia (BPH). The pressure of an enlarged prostate may produce symptoms that include: a frequent or urgent need to urinate; a delayed or weak urinary stream; and the need to urinate several times at night.

The good news is that reliable diagnostic tests and numerous treatment options are available for prostate cancer and enlarged prostate, and death rates from prostate cancer are on the decline. However, with so many treatment options now available, men with BPH or prostate cancer sometimes have difficulty deciding on the right treatment, and the long-term lifestyle effects that each of these prostate disease treatments may cause.

About this Website: Prostate

For the Johns Hopkins Health Alerts on Prostate Disorders, Dr. Jacek L. Mostwin, Dr. H. Ballentine Carter, M.D., and other prominent specialists in Adult Urology at the Johns Hopkins University School of Medicine review the latest research in managing prostate cancer, BPH, and other prostate disorders.

They also bring the latest research and findings on the various types of prostatitis, a inflammation of the prostate which can also affect the quality of life for many men, and which up until now, has not been fully understood.

Johns Hopkins Urology specialists provide current information on key prostate disease issues such as PSA testing, and how to interpret the new PSA levels and your Gleason score if you have had a prostate biopsy.

You will find clear explanations on the newest BPH treatments, and how the minimally invasive BPH treatments for prostate TUNA and TUMT compare with TURP. You will also find advice on when to adopt 'watchful waiting', and which 'alternative remedies' actually do help prostate disease.

Our experts also discuss the many aspects of prostate cancer, from prevention, to diagnosis, to treatment.

Johns Hopkins specialists also cover the range of other genitourinary conditions which can result from prostate disease and prostate disorders treatments. These prostate health related conditions include overactive bladder, various kinds of urinary incontinence, and erectile dysfunction. Johns Hopkins experts explore in depth the current prostate medications and other treatment options available so you can know all your options before making any decisions.

We are continually updating this website, so please visit and bookmark the Prostate Disorders Topic Page so you can easily check back to see what's new in the world of prostate cancer and prostate disorders treatments.

Two Studies Link Erectile Dysfunction with Cardiovascular Disease

Thu, 06 Mar 2008 06:00:00 CST

Two Studies Link Erectile Dysfunction with Cardiovascular Disease

Erectile Dysfunction Linked to Cardiovascular Disease and Diabetes

A study of nearly 4,000 men with an average age of 57 found that nearly half had experienced erectile dysfunction in the last month or were taking erectile dysfunction drugs. The development of erectile dysfunction was strongly related to the presence of cardiovascular disease (CVD) and diabetes, probably because of their negative effects on blood vessel function.

The relationship between erectile dysfunction and CVD or diabetes was most pronounced among men age 40–49. In these men, the probability of having erectile dysfunction was 31% in the absence of either medical condition but rose to 52% in men with CVD alone and to 73% in those who had CVD and diabetes. The relationship between erectile dysfunction and CVD or diabetes was apparent in all age groups but declined with age.

The researchers also found a significant association between erectile dysfunction and undiagnosed diabetes or elevated glucose levels that put the men at risk for diabetes. Erectile dysfunction also correlated with the presence of the metabolic syndrome, a cluster of heart disease risk factors. This study was reported in the Archives of Internal Medicine (Volume 166, page 213).

Erectile Dysfunction May Signal Undiagnosed Heart Problems

Cardiovascular disease is known to increase the risk of erectile dysfunction. But a new study suggests that erectile dysfunction can also be an important warning sign of unsuspected heart disease.

The participants, all age 55 or older, were taken from the Prostate Cancer Prevention Trial (PCPT), which tested the benefits of finasteride (Proscar) in preventing prostate cancer among nearly 19,000 men. The current study analyzed information on the 4,247 men in the placebo group who had no erectile dysfunction or cardiovascular disease at the outset of the PCPT. Five years later, 57% of them had developed erectile dysfunction. At seven years, the percentage had climbed to 65%. During the same follow-up period, men who developed erectile dysfunction were 25% more likely than men who did not have erectile dysfunction to experience some kind of cardiovascular event, such as angina, a heart attack, or a stroke.

As a cardiovascular risk factor, erectile dysfunction ranks with current smoking or a family history of heart attacks. If you develop erectile dysfunction, therefore, it is not merely a lifestyle issue. It is also an important warning of the risk of cardiovascular disease and should prompt an investigation of your cardiovascular status and appropriate treatment when necessary. This study was reported in the Journal of the American Medical Association (Volume 294, page 2996).

Obesity, Hyperglycemia, and BPH

Thu, 24 Jan 2008 06:00:00 CST

Benign prostatic hyperplasia (BPH) is the most common benign growth process in men. But the cause of this serious condition is not well understood. A recent Hopkins study sheds light on a possible link between enlarged prostate, hyperglycemia, and obesity.

The term hyperplasia refers to an overgrowth of tissue or any abnormal accumulation of cells that causes an organ or area of the body to enlarge. In benign prostatic hyperplasia (BPH), prostate cells accumulate, and the tissue overgrowth produces nodules in the transition zone of the prostate. The increase in prostate cells is due to a slowing of apoptosis (normal programmed cell death), not because of an increase in cell production.

What triggers BPH is not well understood, but aging and testosterone (the predominant male sex hormone) are believed to be the primary influences on its development. Animal studies suggest that the female sex hormone estrogen (produced in small amounts in men) may also play a role in BPH, perhaps when a man’s testosterone production declines and the balance of the two hormones is altered.

Johns Hopkins researchers recently participated with the National Institutes of Health in a study designed to examine possible associations between BPH, obesity, and diabetes. Results of the study were reported in the Journal of Clinical Endocrinology and Metabolism (Volume 91, page 2562).

The researchers used magnetic resonance imaging (MRI) to assess prostate volume in 422 men who were participating in the ongoing Baltimore Longitudinal Study of Aging. They calculated each man’s body mass index (BMI) and did blood tests designed to detect elevated fasting glucose levels, including those high enough to indicate diabetes.

Compared with normal weight men of the same age, very obese men were 3.5 times more likely to have an enlarged prostate. Elevated fasting glucose levels tripled the risk of developing enlarged prostate or BPH. Diabetes more than doubled the risk. Obesity and elevated glucose levels are components of the metabolic syndrome, which is known to promote inflammation, production of toxic particles known as free radicals, and growth factors. These influence the development of prostate cancer and might also promote benign growth of the prostate gland.

Prostate Cancer in the Family

Thu, 03 Jan 2008 06:00:00 CST

Is there a history of prostate cancer in your family and if so, what should you do? In this Q & A from an issue of the Johns Hopkins Prostate Bulletin Dr. Jacek Mostwin gives advice to a reader from California with prostate cancer in the family.

Question. My grandfather died of prostate cancer at 58, and a first cousin on my father’s side was also diagnosed with prostate cancer at 66; he sought treatment, and lived to 75.

I am 57 and my prostate is not enlarged. My PSA was first measured in 2003, and it was 8 ng/ml. I have had it checked every six months since then and it has gone as high as 10.5 ng/ml. Two in-office prostate biopsies have revealed no cancer. After suffering urinary retention, I was catheterized last fall, but otherwise have had no particular problems with urination.

I follow a low-fat diet and take a daily multivitamin, plus 300 mg of vitamin C. I am concerned with my family history of prostate cancer and wonder if I should be doing anything in particular to protect myself? Sacramento, CA

Dr. Mostwin answers: You have more than twice the risk of most men of having prostate cancer, yet two prostate biopsies have been negative, despite the high PSA. Your PSA may be high because of a large volume of benign disease, or because of inflammation or congestion.

If there has been an episode of retention, it suggests significant obstructive trouble. Retention is usually considered an indication for surgical treatment. In this situation, depending on the patient’s age, I have previously performed TURP (transurethral prostatectromy) to relieve outflow symptoms and to harvest a large amount of tissue for biopsy from the central portion of the prostate.

One of the advantages of performing TURP in this setting is the acquisition of the tissue for pathological examination. If cancer is found, the grade and amount can be determined, and treatment recommendations provided. If there is no cancer, or only an insignificant amount, the result can be very reassuring, and conservative surveillance can continue afterwards. This approach would be most suitable in a case where the primary choices after TURP would be between radiation treatment and further watchful waiting. I would be very cautious about performing or advising TURP in a patient whom I thought would be a candidate for radical prostatectomy if cancer were found.

Editor’s note: TURP is the "gold standard” treatment for benign prostatic hyperplasia (BPH). In this procedure, a long, thin instrument called a resectoscope is passed through the urethra into the bladder and used to cut away prostate tissue and seal blood vessels with an electric current.

PSA as an Effective Early Marker of Prostate Cancer

Thu, 13 Dec 2007 06:00:00 CST

Johns Hopkins Health Alerts | Prostate Disorders | Early Marker of Prostate Cancer

Dr. Jacek L. Mostwin, Medical Editor of the Johns Hopkins Prostate Bulletin, shares insights from this year’s American Urological Association Annual Meeting. His comments on PSA testing come from a recent issue of the Prostate Bulletin.

Dr. Mostwin writes: As you probably know, PSA, or prostate specific antigen, is a protein produced by cells within the prostate, and blood levels of PSA can be measured in the blood. While higher PSA blood levels are often noted in men with prostate cancer, PSA elevation is not specific for prostate cancer. That said, at present, an elevated PSA test value (4.0 ng/ml or higher) is the most common way that prostate cancer is detected in the United States.

At a press briefing to describe his interesting study, Hans Lilja, M.D., Ph.D., an attending research clinical chemist at Memorial Sloan-Kettering Cancer Center in New York, detailed how a single PSA test given to more than 21,000 men in their early 40s was highly predictive of their developing advanced prostate cancer 20 to 25 years later. More than 60% of advanced cancers (T3) that developed over a 25-year period were associated with PSA values in the 80th percentile or greater among men between the ages of 44 and 50. “It’s fascinating to realize that 20 to 25 years away from the baseline sample, this (PSA) biomarker is so informative,” Dr. Lilja told the assembled reporters.

Data for Dr. Lilja’s study came from archived blood samples that had been collected and stored in Malmö, Sweden between 1974 and 1986. By 2000, 161 men had developed advanced prostate cancer. Their PSA values were then compared with those of 500 age-matched controls. Small elevations in PSA increased the risk of developing advanced prostate cancer. By age 75, men whose PSA was 0.5 ng/ml at the time of sampling, years earlier, had a 2% likelihood of developing T3 prostate cancer. However, if the original PSA level was 2 ng/ml or higher, the risk of advanced cancer was 12%, a sixfold jump.

"PSA is highly controversial,” said Dr. Lilja, “but obviously a PSA test taken early in life, before the age of 50, has an undoubtedly high capacity to predict future risk of prostate cancer, and cancer of unquestionable significance.”

What this study suggests supports what my Hopkins colleague, H. Ballentine Carter, M.D., has suggested previously, based on his own PSA studies. That is, that men should have a PSA test in their 40s. Based on that PSA reading, a man could be placed in a low- or high-risk group, which would then determine how frequently his PSA is monitored over the next two decades.

Bottom line advice: At present, men are urged to have their first PSA test at age 50 -- an age chosen randomly and based on no real science. "This study looked at the development of advanced disease that is threatening to a man’s life, and it could help predict this,” said Christopher L. Amling, M.D., Director, Division of Urology, UAB Hospital, Birmingham, Alabama, and moderator of the press conference. "There should be new guidelines on how we screen for prostate cancer. These guidelines may appear soon, and this study certainly supports that.”

Johns Hopkins Health Alerts | Prostate Disorders | Early Marker of Prostate Cancer

Grand Rounds Questions and Answers

Thu, 22 Nov 2007 06:00:00 CST

Johns Hopkins Health Alerts | Prostate Disorders | Major Concerns of Radical Prostatectomy

Urinary incontinence and erectile dysfunction are two major concerns of men facing radical prostatectomy. In this dialogue from a recent issue of our Prostate Bulletin, Johns Hopkins specialists respond to patients’ questions about these important issues.

Q. One of the major reasons I decided to have surgery for my prostate cancer was that I thought I would be able to maintain my erections after my prostate was removed. I am 72 years old and I went to a highly-recommended hospital for the prostatectomy. The top surgeon performed the prostate surgery, sparing both erection nerve bundles. Unfortunately, it has been eight months and still no suitable erection.

I have tried 100 mg of Viagra and expected some results within 45 minutes of taking it. However, except for some nasal stuffiness, nothing happened the three times I used the drug. Any thoughts on improvement for me, or is this just the way things are going to be? Tampa, FL

A. It’s unusual for a man to undergo radical prostatectomy over the age of 70 these days, but in selected cases, it is a reasonable choice. The majority of men in this age group, however, will take so long to recover their erections that it’s fair to tell patients in their mid to late 60s that recovery of erections is unlikely, despite perfect nerve bundle preservation.

If you are getting nasal stuffiness from Viagra, it means you are getting adequate blood levels of the drug, so the problem is with the inadequate response of your erectile tissues. A vacuum erection device is one way to help, but in men who wish to be sexually active with the greatest likelihood that their treatment will work, it’s most reasonable to move right to injection therapy.

Q. This is just a note to thank you for your guidance that helped me decide on having surgery for my prostate cancer. I am 62 years old and had been diagnosed with a T1C, Gleason 6 cancer. My prostate surgery was performed at Johns Hopkins and I was home two days after the procedure. I was walking 40 minutes a day soon after. My catheter came out 10 days after surgery, and I have been dry since. Erections are another story, but I am optimistic that erectile function will return on a “reasonable” timetable. My wife is happy to report that there are already hints of life. More importantly, my pathology report indicates the highest probability that my cancer has been removed.

The point I would like to make is that men should not hesitate to have surgery for their prostate cancer. In the hands of a superb surgeon working at a great hospital, you give yourself the best chance for prostate cancer cure. Shaker Heights, OH

A. Congratulations on a great result. Last month we celebrated the 25th anniversary of the first nerve-sparing radical prostatectomy performed by Dr. Patrick Walsh at Hopkins in 1992. That first patient is now 25 years out from his surgery with no sign of prostate cancer and an excellent lifelong functional outcome. Thousands of men have had similar experiences.

One always has to take testimonials such as yours with some caution and compare them to larger studies that take the experience of many men into account. We know that not everyone will have a perfect result from prostate surgery, although we want them to. But when they do achieve cure, continence, and return of erectile function, we are happy, and we want such patients to tell their stories to encourage others facing difficult choices.

Johns Hopkins Health Alerts | Prostate Disorders | Major Concerns of Radical Prostatectomy

What to Look For in a Prostate Cancer Surgeon

Thu, 11 Oct 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Prostate Disorders | What to Look For in a Prostate Cancer Surgeon

Dr. Patrick Walsh, former director of Hopkins’ Brady Urological Institute, shares his insights on choosing a doctor for your cancer surgery.

Dr. Patrick Walsh, dean of prostate cancer surgeons, has performed the technically challenging radical prostatectomy procedure thousands of times, and has personally schooled hundreds of surgeons in the finer points of the difficult nerve-sparing cancer operation. He certainly knows what it takes to be an expert in curing a man of cancer, preserving bladder function, and maintaining the nerves responsible for erections. What about the doctor you’re considering for your own prostate cancer surgery?

"Your doctor may be nice and personable,” says Dr. Walsh,"a practitioner whose empathy for your condition appeals to you, which is great. But what do you know about him? He’s got a terrific bedside manner, but is he a board-certified urologist? What training has he had? Does he know and use the nerve-sparing cancer surgery techniques -- the anatomical approach to radical prostatectomy? How many of these cancer surgeries does he perform annually? What success has he had in preserving potency and continence? If he can’t or won’t give you his rate of success as compared to reports from other surgeons, or to results published in medical journals, this may be a red flag, and perhaps you should look elsewhere for your cancer surgeon.

"You should be able to get a good idea of his success rate in numbers or percentages. In addition, if he hasn’t done very many of these cancer operations -- ideally, hundreds -- you might want to find a more experienced surgeon. Look at it this way: Do you want to be one of the patients he’s learning on? Do you want to be part of someone’s learning curve?

"Remember: You don’t want a surgeon who’s 'pretty good’ at removing the prostate. There are no second chances here: This is a one-shot operation. You are looking for the one surgeon who will perform the one radical prostatectomy you will ever receive in your life, the one operation that will cure your cancer.

"You want a surgeon who is going to make sure that no cancer is left behind, and who knows how to minimize trauma to your body during surgery so you don’t wind up with incontinence, erectile dysfunction, or both.

"Finding the right surgeon may mean that you must travel to a major medical center in another city. This may mean that you’ll be away from home for four days. But after that, even though you may need to wear a catheter for a week or two, the recovery from the operation is usually speedy, and follow- up communication can be carried out over the telephone.

Johns Hopkins Health Alerts | Prostate Disorders | What to Look For in a Prostate Cancer Surgeon

Using PSA Velocity to Predict Prostate Cancer Risk

Thu, 30 Aug 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Prostate Disorders | PSA Velocity to Predict Prostate Cancer Risk

Johns Hopkins researchers have found that PSA velocity can predict prostate cancer many years in advance when it is more curable.

PSA velocity is a measurement of how quickly a man's prostate-specific antigen (PSA) level rises from one year to the next. A rapid rise in PSA (a high PSA velocity) suggests the presence of prostate cancer. A study from Johns Hopkins and the National Institute on Aging found that an increase in PSA level of more than 0.75 ng/mL per year was an early predictor of prostate cancer in men with PSA levels between 4 ng/mL and 10 ng/mL.

PSA velocity is especially helpful in detecting early cancer in men with mildly elevated PSA levels and a normal digital rectal exam. It is most useful in predicting the presence of cancer when changes in PSA are evaluated over at least one to two years. In a study reported in The New England Journal of Medicine, a rapid rise in PSA level (more than 2 ng/mL) in the year before prostate cancer diagnosis and surgical treatment predicted a higher likelihood that a man would die of his cancer over the next seven years.

Now a study by Johns Hopkins researchers shows that PSA velocity can predict which men will develop life-threatening prostate cancer many years later. The study subjects were 980 men who had been long-time participants in the Baltimore Longitudinal Study of Aging, sponsored by the National Institute on Aging.

The researchers found that PSA velocity measured 10–15 years before prostate cancer diagnosis predicted their cancer-related survival 25 years later. Ninety-two percent of the men whose PSA velocity was 0.35 ng/mL or less per year had survived, compared with 54% of those whose PSA velocity was greater than 0.35 ng/mL per year. About five times more men in the higher PSA–velocity category died of prostate cancer than in the lower-velocity category. When PSA velocity was being measured, most of the men’s PSA levels were below 4.0 ng/mL, the traditional cutoff point for lower risk. These results suggest that PSA velocity may help identify high-risk men early, when their disease is more curable. This data was reported in the Journal Of The National Cancer Institute (Volume 98, page 1521).

Johns Hopkins Health Alerts | Prostate Disorders | PSA Velocity to Predict Prostate Cancer Risk

Calcium: Friend or Foe?

Tue, 11 Mar 2008 15:30:10 CST

Johns Hopkins Health Alerts | Prostate Disorders | Calcium: Friend or Foe

Calcium has important health benefits, but consuming too much calcium may increase the risk of prostate cancer.

Calcium, a mineral abundant in dairy products, is important for maintaining strong bones and teeth and preventing the bone thinning disease osteoporosis. Studies also suggest that an adequate calcium intake reduces the risks of hypertension and colon cancer.

In light of these benefits, the latest Dietary Guidelines for Americans, which were issued in 2005, recommend that all adults consume three cups of fat-free or low-fat milk each day, or the equivalent in low-fat cheese or yogurt. The Institute of Medicine also advises a calcium-rich diet, recommending that men and women over age 50 consume 1,200 mg of calcium per day.

For older men, the calcium picture is not entirely clear. Accumulating research suggests that consuming too much calcium increases a man’s risk of developing prostate cancer.

In an article published in the December 7, 2005, issue of the Journal of the National Cancer Institute, researchers analyzed 12 studies that examined a potential link between calcium consumption and prostate cancer. They found that men who consumed the most dairy products had an 11% increase in risk compared with men who consumed the least. When they analyzed the results by total calcium intake (dairy products and other sources of calcium), the increased risk was 39%.

Last year, research from the Health Professionals Follow-Up Study (a long-term study of nearly 50,000 male health professionals) also found a link between prostate cancer and a high consumption of calcium. But that study, which appeared in Cancer Epidemiology, Biomarkers and Prevention, associated high calcium intake primarily with advanced and fatal prostate cancer.

Men who consumed 1,500 - 1,999 mg of calcium per day were nearly twice as likely to be diagnosed with life-threatening prostate cancer as were those who consumed 500–749 mg per day; the risk was nearly 2.5 times higher for men who consumed 2,000 mg or more per day. The researchers noted that high calcium levels suppress the active form of vitamin D (1,25-dihydroxyvitamin D3), which is believed to regulate the normal growth of prostate cells. Other researchers have pointed to calcium's effects on insulin-like growth factor-1 (IGF-1), which stimulates the growth of prostate cancer cells.

Bottom line advice on calcium and prostate cancer: Concerns about calcium and prostate cancer need to be put into perspective because calcium has important health benefits. Moreover, in the amounts that most men consume, the increase in prostate cancer risk is modest. The prudent approach, for now, would be to limit calcium consumption to the 1,200 mg per day recommended by the Institute of Medicine. Food sources are the best bet and can quickly add up to 1,200 mg.

Johns Hopkins Health Alerts | Prostate Disorders | Calcium: Friend or Foe

Fighting Prostate Disease with Phytotherapy

Thu, 20 Sep 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Fighting Prostate Disease with Phytotherapy

While many men elect to use plant-based substances to manage symptoms of prostate disease such as BPH, the science on phytotherapy is inconclusive and sometimes contradictory.

Phytotherapy -- the use of herbs or other plant-based products to prevent or treat a health condition -- is popular among men with prostate problems. In fact, a study reported in Urology found that one third of prostate cancer patients had used some form of alternative or complementary medicine: vitamin or mineral supplements, herbs, antioxidants, or supplements promoted for "prostate health.”

Phytotherapy for prostate problems encompasses a wide range of approaches. At one end of the spectrum are healthful foods like tomatoes, cooked tomato products, and pomegranates, for which there is some evidence of protection against prostate cancer. Processed nutritional supplements like saw palmetto are next, providing concentrated amounts of plant components. Products in the third category, raw herbs, undergo the least scrutiny for content and purity. Therefore they pose the greatest risk of potential contamination and toxicity.

It's hard to go wrong by eating reasonable amounts of prostate healthy foods. But solid research into the benefits and potential risks of these remedies is scarce, and the available evidence is often contradictory.

For example, a new analysis from the Health Professionals Follow-Up Study (HPFS) suggests that overall diet has little effect on prostate cancer risk. More than 50,000 men have participated in HPFS since 1986, when it began to explore the links between diet and various diseases.

The current analysis, reported in the journal Cancer Epidemiology, Biomarkers and Prevention (Volume 15, page 167), examined the diets of 3,002 men who had developed prostate cancer by the year 2000. Researchers characterized their diets as "western” or "prudent.” The western diet was one higher in meats, refined grains, and high-fat dairy products. The prudent diet emphasized fruits, vegetables, whole grains, fish, and poultry.

In general, the study showed no association between mens' dietary patterns and their overall prostate cancer risk or diagnosis of advanced prostate cancer. Among men age 65 or older, there was a modest association between a western diet and advanced prostate cancer, linked primarily to eating processed meats. This is not the last word on diet and prostate cancer. Other research has shown links between prostate cancer risk and various dietary components. Plus, the prudent diet is a good idea for its many other benefits.

Johns Hopkins Health Alerts | Prostate Disorders | Fighting Prostate Disease with Phytotherapy

Joining a Clinical Trial

Thu, 09 Aug 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Joining a Clinical Trial

Michael A. Carducci, M.D. , Associate Professor of Oncology and Urology at Johns Hopkins, explains why you might want to enroll in a clinical trial if you have advanced prostate cancer.

Even though all patients want therapies that will keep their cancer in check, it is estimated that only 3% of the possible number of people who would be candidates for clinical trials of novel cancer agents actually enroll in clinical trials. What will help push the science forward at a greater pace is having more men enroll in clinical trials of experimental prostate cancer therapies.

You might want to join a clinical trial for a number of reasons, for example:

If you have advanced prostate cancer, you might hope for remission, or even for a cure.

You might see participation in a clinical trial as providing access to free, high-quality treatment.

You might be altruistic and simply want to help advance medical knowledge through participation in a clinical trial.

Clinical trials also provide answers to more basic questions that are vital when developing a new drug: Can an injection get the medicine to you faster than a pill? Does the newest painkiller make you less drowsy than the others?

The engine of medical progress depends on data from clinical trials for fuel, but getting the best data requires the willing participation of hundreds or thousands of people. Here's how a study works. Studies always begin in test tubes and in animals. If results are promising, patient recruitment begins for the different phases of the study.

Phase I clinical trial evaluates drug safety in a few dozen subjects with advanced disease, determines dosage, and identifies side effects.

Phase II clinical trial involves up to a few hundred participants, but is typically small -- in the range of 30 to 40 patients.

Phase III clinical trial gathers more definitive results by determining benefits and risks in a larger number of people. Hundreds or thousands more people are enrolled, and treatment results are measured against placebo or existing treatments.

Phase IV clinical trial occurs after the FDA approves the medication and it becomes available to the public, usually by prescription. This phase examines long-term effectiveness and side effects.

Bottom line advice: To find a clinical trial of an investigational medication for advanced prostate cancer, contact your local hospital or medical center, or ask your doctor to help. Be wary of claims in advertisements, and make sure your health costs are covered. The following groups can help direct you to clinical trial of novel prostate cancer therapies. If you meet enrollment qualifications, you can also enroll in one of the several ongoing studies at Johns Hopkins.

National Institutes of Health Phone: 888-346-3656 www.clinicaltrials.gov

Centerwatch Inc. Phone: 800-765-9647 www.centerwatch.com/patient

Johns Hopkins University School of Medicine, Clinical Trials Unit Phone: 410-955-7669 www.hopkinsclinicaltrials.com

Sidney Kimmel Comprehensive Cancer Center Phone: 410-955-8804 www.hopkinskimmelcancercenter. org/clinicaltrials

Johns Hopkins Health Alerts | Prostate Disorders | Joining a Clinical Trial

Consider Complementary Therapies: Key 7, Seven Keys to Treating Prostate Cancer

Sun, 22 Jul 2007 11:24:50 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Consider Complementary Therapies: Key 7

Seven Keys to Treating Prostate Cancer

Key Seven: Consider Complementary Therapies
The thrust of our mainstream Western medical approach to cancer treatment has been aggressive attempts to eradicate all malignant cells, oftentimes at the expense of a person's quality of life. In the 18th century, Dr. John Hunter observed, "Surgery is like an armed savage who attempts to get back by force what a civilized man would get by stratagem." Complementary medicine, which can include yoga, acupuncture, meditation, dietary changes, and herbal remedies, may be that civilized stratagem Dr. Hunter was talking about. What complementary medicine can do so well is help to unite the body, mind, and spirit in health, even providing some relief of cancer symptoms with few, if any, side effects.

Complementary treatments offer cancer patients—especially those with advanced forms of the disease—a glimmer of hope, and with that hope, the quality of one's life improves, increasing survival in the process. When used in conjunction with conventional medicine, many prostate cancer experts believe complementary medicine has a positive role to play in the management of the prostate cancer patient.

What is Complementary Medicine?
The term "complementary medicine" covers an enormous spectrum, from non-Western practices such as Ayurveda, to South American and European folk traditions, to homeopathy and chiropractic. Some of these practices— massage, meditation, acupuncture, yoga, and laying on of hands—have existed for centuries.

Here's a brief overview of three of the more popular complementary medicine therapies:

Meditation
Meditation is an age-old practice that helps divorce the mind from life's daily problems, bringing on such potentially beneficial changes as lower blood pressure and reduced heart rate in the process. Accomplished practitioners, it's been shown, can also lower their oxygen consumption and body temperature and for that reason meditation is sometimes recommended to people with heart disease or other medical problems, as well as to anybody who's trying to control emotional stress.

The word "meditation" means many different things to different people. Most commonly it requires sitting or lying quietly in a prescribed position, usually with the eyes closed, so that attention is withdrawn from the outside world and from customary activity, and repeating a word or phrase (called a mantra) such as "Om" aloud or silently.

Meditation is not difficult to perform. Some forms of meditation involve concentrating on breathing in and out, while others repeat a word, sound, phrase, or a simple prayer aloud or silently. As you do so, gently set aside any distracting thoughts that try to push their way in. It's simple to get started: Begin with one breath. Just tune in to the feeling of it as you inhale and concentrate on the sound of your breath leaving your body. That's all. Just feeling the breath, breathing and knowing that you are breathing should keep you focused in the present, taking you away from restless, wandering thoughts, and putting you right in the here and now.

Yoga
The mind-body-spirit discipline of yoga has so much to offer. Yoga, which means "union" or "harmony" in Sanskrit, has its roots in the Hindu culture of India, where evidence of yoga practices dates back 6,000 years. Over the centuries, it developed both as a philosophy— which holds that the mind, body, and spirit are inseparable—and as a system of exercises to improve physical health. These exercises consist of more than 1,000 carefully controlled moves and poses designed to develop balance, flexibility, and increased strength. Equally important are the breathing exercises, intended to focus concentration and relieve stress. By going through a daily system of yoga postures and breathing techniques that calm the mind and boost the spirit, many people find that they're able to relax physically and get in touch with their body and therefore their mind.

Support Groups
Whatever promotes a sense of loneliness and isolation, either from yourself or from other people predisposes you to disease or premature death. Something happens in your body when you're feeling well loved and taken care of, as well as when you give love back in return. On the contrary, social isolation, loneliness, and alienation contribute to ill health and have long been associated with the very high risk of premature death from all causes—and there are hundreds of studies to back this up.

A very interesting study was performed at Johns Hopkins in 1940 to assess how the closeness of 1,100 healthy male medical students to their fathers would lead to enhanced health— and fewer incidences of cancer—later on in life. What the researchers found was that 50 years later those men who went on to develop cancer were more likely to have described a lack of closeness with their fathers early on in life. The researchers also found that those men who developed malignant tumors had suffered more from loneliness years before.

Love, caring, and psychological support play important roles in men with prostate cancer, increasing survival time dramatically for married men. A 1996 study, "Marriage and Mortality in Prostate Cancer," published in The Journal of Urology points to a strong mind/body/prostate link. Researchers from the University of Miami evaluated more than 143,000 men with prostate cancer diagnosed between 1973-90, looking closely not only at the stage of disease at diagnosis and type of treatment they underwent, but also at their length of survival and their marital status.

Their findings: Marriage offered a strong protective effect. The median survival time for separated and widowed men was 38 months; single men died at 49 months; divorced men survived 55 months on average; and married men lived 69 months, nearly twice as long as a widower.

The impact of social support on the progression of some cancers is evident. It may take some time for society—and physicians—to accept the idea that love and relationships can heal, but there is now plenty of research to support it.

Johns Hopkins Health Alerts | Prostate Disorders | Consider Complementary Therapies: Key 7

Understand the Role of Diet in Preventing Prostate Cancer: Key 6, Seven Keys to Treating Prostate Cancer

Sun, 22 Jul 2007 11:24:25 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Understand the Role of Diet in Preventing Prostate Cancer: Key 6

Key Six: Understand the Role of Diet in Preventing Prostate Cancer

Does what you eat help prevent prostate cancer? Do certain foods slow down its progression when it recurs? If how much you eat and what you eat—and what you avoid— works so well in preventing heart disease, then will it do the same for prostate cancer? For the one in six American men diagnosed with prostate cancer in their lifetime, these are just some of the questions for which they and many other concerned men want answered.

Based on epidemiological studies, in which researchers use food diaries, diet recalls, or questionnaires to closely examine what people eat, it's now believed that diet is one of the most important lifestyle factors that can influence cancer rates of many organs. The problem is that researchers haven't been able to specifically identify which components of the diet have the most effect.

Cancer experts estimate that diet accounts for up to 90% of cancers of the prostate, large bowel, breast, and pancreas—even lung cancer may have a dietary link. And we do know that people who consume plenty of vegetables, fruits, and grains and who exercise regularly, are less likely to develop various cancers—possibly including cancer of the prostate—than those who don't.

Scientific evidence suggests that differences in diet and lifestyle may account in large part for the variability of prostate cancer rates around the world. Researchers are now hard at work examining the foods we eat to see exactly what they contain and what affect they have on the prostate.

We do know, for example, that the prostate cancer rate for Asian countries, where the diet is primarily vegetarian, is ten times lower than it is for the United States, where meat and potatoes still rule. Looking at the mortality rates in Japan compiled by the World Health Organization (WHO) between 1990 and 1993, we see there were four deaths from prostate cancer per 100,000 men. Japanese men typically consume a diet high in soy-based foods, such as tofu, tempeh, and soymilk, and they eat plenty of fruits and vegetables. In the United States, where daily meat and fat consumption (which may affect hormones and cause chemical changes that may have the potential to make tumors grow) is much higher, the WHO death rate was more than four times higher than Japan's.

There are several possible reasons why people in Asian countries such as Japan and China are far less likely than Westerners to develop cancer of the prostate. Some believe there are important genetic differences between ethnic groups and that this difference in cancer rates could be specifically related to our genes. Interestingly, though, when people migrate from Japan to the United States, their rates of prostate cancer and the rates in subsequent generations rise markedly. Since genetic makeup is unchanged, the increase in risk is likely related to environmental factors such as diet and lifestyle.

Diet Does Matter
There is certainly a great deal of anecdotal evidence pointing to diet as a major contributing factor in predisposing some men to prostate cancer or accelerating progress of the disease in others.

Whether or not diet can help in the prevention or treatment of prostate cancer is a difficult question to answer scientifically at present.

However, a lack of scientific evidence does not necessarily mean a lack of benefit but rather that not enough research has yet been completed in this area. Of all the risk factors for prostate cancer, diet certainly seems to correlate with the difference in global distribution of the disease.

Diet does matter ;we just haven't been able to identify one particular component or constellation of components that scientists all agree have a preventive effect. Not one particular nutrient or food will offer the "magic bullet." What it may turn out to be is a combination of energy balance— calories consumed, calories expended— and the type of diet consumed that may provide the ultimate answers.

The good news is that diet is a risk factor that can be altered by every individual. Although eating habits are hard to change, what and how much food we eat is our choice, and under our control compensating with increased physical activity.

Fast food outlets, the huge increase in portion sizes at restaurants, and the many hours spent watching television, or using computers are all contributing to this epidemic of obesity. Food and good health
Perfect diets are no guarantee of perfect health.

Even if you do everything right in terms of nutrition, some of us will still get prostate cancer.

Because we know that diet and lifestyle are important for the prevention of other chronic diseases, such as heart disease, hypertension, and diabetes, a good recommendation at present is to follow the nutrition and lifestyle guidelines of the American Cancer Society.

Here are the key parts to remember:

Choose most of the foods you consume from plant sources. Consume five or more servings of fruits and vegetables per day.
Be sure to consume a variety of brightly colored fruits and vegetables

Limit your intake of high-fat foods, particularly from animal sources. Choose foods low in fat. Limit consumption of meats, especially high-fat meats. High-fat diets have been associated with an increased risk of prostate cancer, as well as cancers of the colon and rectum.
Ongoing research increasingly suggests that consuming a mostly plant-based, lowfat diet to reduce overall cancer risk may also reduce the risk of prostate cancer. People who are described as consuming "highfat" diets are generally consuming greater amounts of fatty meats and dairy products, both of which may be linked to an increased prostate cancer risk

Be physically active and maintain a healthy weight.

Limit consumption of alcoholic beverages, if you drink at all. If you drink, do so in moderation.
Some studies show that limited amounts of alcohol may modestly lower the risk of heart disease, but alcohol can also lead to an increased cancer risk.
Talk to your doctor about what amount of alcohol consumption is appropriate for you Increasing the amount of exercise you perform and improved eating habits may be better ways to improve and preserve general health.

The Western medical approach to cancer treatment has been aggressive attempts to kill all malignant cells.

But as you will discover in Key #7, complementary medicine can unite the body, mind, and spirit in health, while providing some relief of symptoms with few side effects.

KEY 7 is titled: Consider Complementary Therapies This Special Report is not intended to provide advice on personal medical matters or to substitute for consultation with a physician Copyright © 2006 Medletter Associates, LLC All rights reserved

Johns Hopkins Health Alerts | Prostate Disorders | Understand the Role of Diet in Preventing Prostate Cancer: Key 6

Psychological Issues of Prostate Cancer: Key 5, Seven Keys to Treating Prostate Cancer

Sun, 22 Jul 2007 11:24:02 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Psychological Issues of Prostate Cancer: Key 5

Key Five: Seek Extra Help—If Needed

If you were to ask any patient diagnosed with prostate cancer what was important to him, he may not mention psychological issues.
However, the overwhelming apprehension triggered by the diagnosis, or the disconcerting uncertainty of what the future holds in terms of treatment and outcome, may be at the forefront of his mind. Unfortunately, these are not issues surgeons or radiation therapists typically discuss with patients.

Here are some random thoughts men typically have after their diagnosis:

I am afraid of death

Why me?

I can't believe this is really happening

Will I ever have sex again?

Will my wife leave me if I can't get an erection?

I'm so angry I don't know what to do

I feel alone. It's a nightmare

I think about cancer all the time

I can't articulate what I want to say about how I'm feeling right now

Will my life ever be "normal"?

I'm so upset that my family has to go through this

It's natural to feel upset and worried when faced with a cancer diagnosis. Unfortunately, while many prostate cancer patients go on to receive excellent medical attention, their psychological needs are often ignored. Studies show that a significant number of cancer patients eventually develop serious anxiety and depression that is left untreated. Doctors typically don't ask about a patient's emotional state because they're often busy taking care of the medical issues and patients don't tell because they don't want to appear "un-manly" or seem like someone who is not coping well.

Recently diagnosed prostate cancer patients often need treatments not just for their bodies, but can benefit from treatment for their minds, and the same goes for patients whose cancer has returned. Although a person can't change the course of his illness with his mind, he can certainly improve the quality of his life by examining how he is reacting to his illness. Evidence shows that when people with cancer get the emotional support they need, they do better. Sometimes they don't do better in terms of survival, but certainly, they make great strides in terms of overall quality of life and emotional wellbeing.

Psychological Concerns Caused by Surgery
The uncertainty of the outcome following prostate cancer surgery bothers many men. Will I make it through the surgery? Will I be cured? Will I be continent? Will I be able to have a hard erection ever again? What generally happens is that before a person decides on a course of treatment, he may be quite anxious and sad. Once he opts for a radical prostatectomy, finally has the surgery, and starts to recuperate, he generally starts to feel better adjusted. That's because one of his biggest uncertainties and fears will have been answered— he has survived.

Psychological Worries Caused by Radiation Therapy
The fears may be somewhat different compared to men undergoing surgery because radiotherapy is an eight- or nine-week process of going to the hospital every day for treatment. Some men find comfort in this routine because they feel they are being proactive and part of the healing process: every day they are doing something positive to treat their cancer. Others may feel scared: is today's treatment going to kill enough cancer cells to ensure survival? Is the radiation going to get all the cancer by the time I've finished the treatment? For these men, it may take a bit longer for them to develop an assurance that they've done everything possible to successfully treat their cancer.

They will also be concerned about urinary incontinence and erectile difficulties.

Seeking Help
There is plenty of controversy surrounding prostate cancer treatment. However, a sympathetic friend who already had his cancer treated, a compassionate clergy member you can confide in, or a prostate cancer support group can help relieve feelings of anxiety and depression. A support group generally offers good, solid information covering the whole gamut, from diagnosis, treatment, and recovery to the best doctors, new study results, and clinical trial enrollment.

A psychologist, psychiatrist, or social worker can also help many prostate cancer patients. You can find these professionals through a local prostate cancer support group, a community hospital, or through your family doctor or urologist.

For recently diagnosed men, there is often a lot of distress, because they are not exactly sure what to do about their cancer. Some have seen a couple of urologists; others have consulted with a radiation oncologist. With a number of excellent practitioners recommending different treatments, it's often up to the men to now make the decision as what is the best treatment for them. A mental health professional can help provide advice to make the decision making a bit easier.

Antidepressants for Prostate Cancer Patients
Most men recently diagnosed with prostate cancer do not need any psychotropic medication.

However, there are some men who are plunged into despair because of their diagnosis, or else they become extremely agitated and anxious. Medical treatment is readily available for these men. Any man who feels he needs the assistance of medication or psychotherapy, or both, should mention this to his doctor. The good news is that the anxiety and depression often responds well to these medical interventions.

Does what you eat help prevent prostate cancer? Key #6 explains why diet does matter and that it's a prostate cancer risk factor that can be altered by every individual.

KEY 6 is titled: Understand the Role of Diet

This Special Report is not intended to provide advice on personal medical matters or to substitute for consultation with a physician Copyright © 2006 Medletter Associates, LLC All rights reserved

Johns Hopkins Health Alerts | Prostate Disorders | Psychological Issues of Prostate Cancer: Key 5

Restore and Maintain Erectile Performance: Key 4, Seven Keys to Treating Prostate Cancer

Sun, 22 Jul 2007 11:23:37 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Restore and Maintain Erectile Performance: Key 4

Key Four: Restore and Maintain Erectile Performance

If erectile dysfunction (ED) is something you worry about or have already experienced, whether it is occasional or more frequent, help is now available. Remember: ED has a profound affect on the lives of the people it touches.

Countless marriages and long-term relationships have been broken by it; people who otherwise cared deeply for each other felt separation was a better solution; and innumerable others continued to live together sexually unfulfilled.

Sex is, of course, not the only component of a strong and lasting relationship, but it is an important one. Moreover, if ED is a problem, the variety of therapies now available will not only treat it, they will help you renew your bond with the person you care most about.

Sexual Side Effects of Prostate Cancer Surgery
Advances in early detection of prostate cancer and improved surgical procedures have greatly improved survival rates. However, removal of the prostate can also affect the ability to have an erection suitable for intercourse even when a talented surgeon performs the procedure.

Prior to the introduction in the 1980s of the nerve-sparing radical prostatectomy procedure by Dr. Patrick C. Walsh, the former Director of the Brady Urological Institute at Johns Hopkins, total ED was a given; Men were never able to have a hard erection following this surgery.

Now with Dr. Walsh's refinements of the surgery, the potency rates at Johns Hopkins are among the best in the world. Dr. Walsh has reported that in the hands of a skilled surgeon performing the nerve-sparing procedure, potency should return in at least 80% of men in their 40s and 50s if both nerve bundles are preserved; at least 60% of men in their 60s should have a return of potency. The numbers drop to about 25% in men in their 70s, most likely because of the aging process, which may affect the function of the nerves they were born with.

Nationwide, the figures for return of erectile performance following a radical prostatectomy are not as impressive as the results at Johns Hopkins, ranging from 14% to 60%, with full erections returning only in those men with both nerve bundles preserved.

Erection Restoration Following a Radical Prostatectomy
Men are concerned about the restoration of erections following their surgery. The time varies, due in part to a man's overall health, age, and erectile hardness prior to surgery. If a man has had one or both nerve bundles preserved, the potential for an erection is certainly there. Men need to be patient, however. Erections return gradually, starting in the first few weeks following surgery. For some men, it can take up to four years to experience full recovery of potency. That's because the body has been through a surgical trauma and simply needs time to recover. In the meantime, don't be discouraged and give up on the idea of sexual intercourse. Week by week, as the nerves recover and blood flow increases to the penis, you will slowly make gains in penile axial rigidity (the scientific name for penile hardness), eventually achieving an erection suitable for intercourse.

ED Following Radiation Therapy for Prostate Cancer
While surgery has an immediate impact on the ability to have a hard erection, the devastating effects of radiation therapy (external radiation and brachytherapy) on erections are generally more gradual. Immediately after radiation therapy, erections may be normal. However, with the passage of months, penile hardness may slowly start to diminish, so much so that by two years post-procedure, achieving an erection suitable for intercourse is sometimes very difficult, if not impossible.

No one is quite certain what is specifically causing the ED following radiotherapy. Some believe that the high doses of radiation eventually damage the arteries that provide blood to the penis. Other researchers point to the damage radiation causes to the neurovascular bundles responsible for erections.

The problem with radiation-induced ED is that once the erectile nerves are destroyed by the radiation, oral erection medications will not work as well. In that case, the patient will have to resort to second-line therapy (injection therapy) or third-line therapy (penile prosthesis) in order to achieve an erection.

The Role of Medications
Some common misconceptions about the three "erection" drugs (Cialis, Levitra, Viagra) must be cleared up first. These ED drugs can play an important role in the restoration of erections, doing so by amplifying the action of important chemicals that trigger erections. However, these medicines are not libido enhancers nor do they cause instant erections after taking them. Nor will they kill you— unless you happen to take a nitrate-based medication (such as heart medications containing nitroglycerin) with them.

In rare instances, men taking these oral erectile dysfunction medicines reported a sudden decrease or loss of vision. It is not possible to determine whether these events are related directly to these medicines or to other factors.

If you experience sudden decrease or loss of vision, stop taking the erection drug, and call a doctor right away.

That said, these drugs can play a very important role in the restoration of erections. If a man has had his neurovascular bundles spared during a radical prostatectomy and was performing well sexually prior to the surgery, he should be able to achieve an erection suitable for intercourse at some time after the surgery.

The stress triggered by a diagnosis of prostate cancer is often enough to cause serious anxiety and depression.

As you'll learn in Key #5, recently diagnosed prostate cancer patients often need treatments not just for their bodies but for their minds as well.

KEY 5 is titled: Seek Extra Help If Needed This Special Report is not intended to provide advice on personal medical matters or to substitute for consultation with a physician Copyright © 2006 Medletter Associates, LLC All rights reserved

Johns Hopkins Health Alerts | Prostate Disorders | Restore and Maintain Erectile Performance: Key 4

Choose the Right Treatment for your Prostate Cancer: Key 3, Seven Keys to Treating Prostate Cancer

Sun, 22 Jul 2007 11:22:42 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Choose the Right Treatment for your Prostate Cancer: Key 3

Key Three: Choose the Right Treatment for your Prostate Cancer

The standard treatment options for prostate cancer include watchful waiting, radical prostatectomy, radiation therapy, and hormonal therapy. Radiation therapy can be delivered from an external source (external beam radiation therapy) or by implantation of radioactive seeds (brachytherapy).
Radical prostatectomy and radiation therapy can potentially cure prostate cancer when the disease is detected in its early stages. Hormone therapy is not curative and is generally used to slow the progression of the disease once it has spread to other sites. Though chemotherapy is effective in treating some types of cancer, it has been less successful for advanced prostate cancer.

Here's a closer look at the various treatment options:

Watchful waiting
This is a management option in which select patients (usually older age) are closely monitored for the progression of cancer rather than undergoing immediate treatment. At Johns Hopkins, men are monitored with regular PSA measurements, digital rectal exams, and an annual biopsy. Watchful waiting also requires that a person be able to live with the cancer and not be overcome by the anxiety of careful monitoring.

Radical prostatectomy
This entails the surgical removal of the prostate gland and seminal vesicles to treat prostate cancer. The anatomical approach to radical retropubic prostatectomy, developed at Johns Hopkins, includes important modifications to reduce blood loss, preserve urinary control, and preserve delicate nerves essential for erections.

Radiation therapy
This therapy uses ionizing radiation to destroy cancer cells by damaging DNA within the cells. With external-beam radiation therapy, treatment is designed to kill cancerous tissue from outside the body by focusing a high-powered X-ray beam on the affected area a few minutes at a time, usually over the course of weeks. Intensity modulated radiation therapy (IMRT) is the newest form of delivering external beam radiation that allows for more precise delivery of calculated radiation dosage to the selected target. Interstitial brachytherapy ("seed" therapy) is another form of radiation therapy in which radioactive pellets ("seeds") are implanted into the prostate to deliver radiation directly to the tumor sites.

Hormonal therapy
This therapy entails the use of hormones to treat advanced prostate cancer, with the goal of shutting down the hormones that nourish the prostate. Some prostate cells are responsive to this, while others are not.

Key Factors to Consider in Choosing a Treatment
Men eventually make their treatment decision based on a variety of factors, including the potential for side effects, perceived long-term risks, psychological ramifications, and financial costs of each of the therapies. While aggressive treatment may prolong life, it can also damage the quality of life by compromising sexual performance and, to a lesser extent, the ability to control urination.

Ultimately, however, prostate treatment depends on two factors: the clinical stage of the cancer (the extent of disease) and the age and general health of the individual.

Researchers have found that, in healthy men who have more than a 10-year life expectancy, about 80% of prostate cancers detected by PSA testing have the potential to progress and thus warrant treatment or careful monitoring. (The PSA test, which measures prostate-specific antigen—a protein produced in the prostate and released into the blood—is widely used as a tool to screen for the presence of prostate cancer.) Still, with increased use of PSA testing, some men will be diagnosed with small prostate cancers (which cannot be felt during a digital rectal exam but are suspected from PSA tests and confirmed by biopsy) that pose no immediate threat and, indeed, may never need treatment. In a small watchful waiting study conducted at Johns Hopkins, after close monitoring and testing, only 30% of the men progressed out of the study to require treatment.

Doctors use several methods to help predict the seriousness of prostate cancer, and this information is factored into the treatment decision.

One method is the Gleason score, which ranges from 2 to 10. A score of 2 to 4 indicates a greater probability of an insignificant cancer—a cancer that is unlikely to grow rapidly and spread.

Higher scores suggest a greater likelihood of a significant, life-threatening cancer. Men with "high-grade" disease (defined as a Gleason score of 7 to 10) are considered poor candidates for watchful waiting, since the high score indicates an aggressive cancer Another method helpful in determining the best treatment option is the Partin tables, named after the Johns Hopkins physician who developed them. The tables help doctors predict whether cancer is confined to the prostate or has spread to adjacent tissue, seminal vesicles, or lymph nodes. (You can view the Partin tables at the Brady Urological Institute web site: http://urology.jhu.edu/prostate/partintables php ).

The prediction is based on the patient's PSA levels, biopsy Gleason score, and TNM cancer stage, which is a system for expressing the size and degree of spread of prostate cancer by separately describing the extent of tumor at its original location (T), whether and to what extent the cancer has spread to nearby lymph nodes (N), and whether and to what extent the cancer has metastasized (M) to other sites in the body.

If cancer has spread outside the prostate, surgery may not be the best treatment option.

You must also consider possible complications when deciding on a treatment option. If a man chooses surgery or radiation therapy, he risks the possibility of bowel, urinary, or sexual problems. If he chooses watchful waiting (no treatment is provided, but the patient is closely monitored for cancer growth), he may be anxious about the progress of the disease, and urinary or sexual symptoms may arise if the disease progresses One of the side effects of prostate cancer surgery and radiation therapy is erectile dysfunction.

In Key #4, you'll learn about the benefits of the three "erection drugs" approved by the FDA.

KEY 4 is titled: Restore and Maintain Erectile Performance This Special Report is not intended to provide advice on personal medical matters or to substitute for consultation with a physician Copyright © 2006 Medletter Associates, LLC All rights reserved

Johns Hopkins Health Alerts | Prostate Disorders | Choose the Right Treatment for your Prostate Cancer: Key 3

Get A Second Opinion about your Prostate Cancer: Key 2, Seven Keys to Treating Prostate Cancer

Sun, 22 Jul 2007 11:22:10 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Get A Second Opinion about your Prostate Cancer: Key 2

Seven Keys to Treating Prostate Cancer

Key Two: Get A Second (and Third or Fourth) Opinion
about your Prostate Cancer Diagnosis and Prostate Cancer Treatment

In an often-cited study published in the Journal of the American Medical Association in 2000, researchers asked more than 1,000 specialists what treatment they would recommend for a man with early-stage prostate cancer who was expected to live at least 10 more years. Nearly all the urologists (93%)—who perform surgery—chose surgery as the preferred treatment, while most of the radiation oncologists (72%) responded that radiation therapy and surgery were equally effective treatments. The study authors' conclusion? Patients should schedule a consultation with a member of each specialty before making a decision.

If these specialists don't agree, one option is to schedule a consultation with a medical oncologist, a specialist in cancer treatment who does not perform radiation or surgery. Another option is to see a second urologist or radiation oncologist. Doctors of the same specialty often have different approaches to treatment: For example, some radiation oncologists will recommend external beam radiation therapy; others, brachytherapy; and still others, a combination.

The Importance of the Pathologist
A final but not-to-be-overlooked reason to seek a second opinion is that if done at a center that specializes in prostate cancer treatments, it involves having another pathologist review the slides from your biopsy specimen. An accurate pathology reading is essential because it forms the basis for treatment decisions Unfortunately, spotting cancerous cells and determining how abnormal they appear are difficult, and pathologists sometimes make errors.

In one study, pathologists at Johns Hopkins reviewed biopsy samples of 535 men who had been referred for radical prostatectomy and reclassified 7 (1.3%) as benign. Upon subsequent clinical workup, 6 of 7 men were considered not to have prostate cancer, and their surgery was canceled. Getting an incorrect reading can limit your treatment options—or lead to having treatments that you don't need.

How To Get a Second Opinion
Your primary care doctor and the urologist who performed the biopsy are the best sources for referrals. Request that, if possible, they suggest a colleague affiliated with a different hospital.

Although this is not necessary, the practice is prudent, because doctors who work at the same institution often share similar views and may be reluctant to contradict one another. Also, check to be certain the consultant is board certified in the appropriate specialty. The American Medical Association ( www.ama-assn.org ) and the American Urological Association ( www.urologyhealth org ) offer referral services. Hospitals, local health departments, family, and friends are other possible resources.

Before meeting with you, the consultant will require all relevant medical records. The first doctor's office can send written reports and test results directly to the consultant. Be sure to call before your appointment to confirm their arrival, as it will be impossible to proceed without proper documentation; you can also choose to collect the records and deliver them personally.

During the consultation, the doctor will review the information and may perform a physical examination or order more tests. Recommendations made in a written report will be sent to the referring physician—and to you if you request them.

Be sure that the specialists address all treatment options—surgery, radiation therapy, and watchful waiting—and discuss the advantages and disadvantages of each. If your doctors don't agree and you don't know what to do, one or more of the following approaches can help you reach a decision:

Have the specialists explain to you why they came to their respective conclusions.

Suggest that the specialists discuss the matter with each other; sometimes such conversations produce an acceptable consensus.

Ask your general practitioner—or, if you wish, another specialist—to help you sort through the options.

Consider seeking an opinion at a nationally recognized cancer center, such as one affiliated with the National Comprehensive Cancer Network ( www.nccn.org).

Try talking to men who have been treated for prostate cancer Don't panic if you're having trouble making a decision. Prostate cancer is generally a slowgrowing malignancy, which means that most people can safely spend several months learning about the disease and consulting with the appropriate specialists.

Making an Appointment at Johns Hopkins
Many people facing a serious health crisis wish to get a second opinion from a leading academic medical center such as Johns Hopkins.

There are several ways to make appointments at Hopkins. The most direct way is for your physician to call the Hopkins Access Line (410-955- 9444 in Baltimore and internationally or 800-765-5447 in the rest of the United States) If you prefer to make an appointment yourself, you may call the appointment service line (410-955-5464 in Baltimore, or 410-955-8032 outside Baltimore, including international calls).

Finally, Johns Hopkins USA provides one point of contact for out-of-town patients. A representative can help you identify an appropriate physician or specialist, coordinate multiple medical appointments, arrange second opinions, and obtain general information about Johns Hopkins's many services. To talk with a representative, call 443-287-0528 weekdays, 8:30 a.m. to 5 p.m. Eastern Time.

Deciding which form of treatment therapy for prostate cancer is best for you entails reviewing a variety of factors.

As you will discover in Key #3, you have several effective options.

KEY 3 is titled: Choose the Right Treatment for Your Prostate Cancer

This Special Report is not intended to provide advice on personal medical matters or to substitute for consultation with a physician.

Johns Hopkins Health Alerts | Prostate Disorders | Get A Second Opinion about your Prostate Cancer: Key 2

Understand Your Prostate Biopsy: Key 1, Seven Keys to Treating Prostate Cancer

Wed, 22 Oct 2008 11:20:54 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Understand Your Prostate Biopsy: Key 1

7 Keys to Treating Prostate Cancer

Key One: Understand Your Prostate Biopsy

When prostate cancer is suspected, either from the results of a digital rectal exam (DRE), a PSA (prostate specific antigen) test, or both, a prostate biopsy is then performed. The procedure involves taking samples of prostate tissue and having a pathologist examine them under a microscope for the presence of cancer.

A pathologist is a medical doctor who examines tissues and takes on the responsibility for the accuracy of laboratory tests for the approximately 800,000 men who have a prostate biopsy each year in this country. Do you want to know what a prostate tissue specimen looks like under the microscope to a pathologist? Imagine a splotchy work of modern art, with countless shades of gray, some black, and variations of black and white shades all swirled together. Within this mass are some normal cells and some that probably are not. From this sample, it's the pathologist's job to determine if there is cancer present and, if yes, how much.

Many patients are unaware of the position of the pathologist in the cancer-detection process, yet these medical specialists play a vital role on the patient's primary health care team.

The pathologist interprets the biopsy results, sending back information that is critical for the patient's diagnosis, decision-making process, and ultimate recovery.

When looking at a prostate biopsy sample, what the pathologist is checking for are specific patterns of prostate cancer cells. Interspersed among healthy cells, prostate cancer cells grow in five recognizable patterns that allow for their identification, or Gleason grade.

By adding the number of the most common pattern to the second most common pattern, a Gleason score is determined. For example 4 + 3 = 7, or 2 + 3 = 5. The Gleason score is the best way that we can assess the aggressiveness of prostate cancer cells. Most men diagnosed with prostate cancer have Gleason scores of 5, 6, and 7. Only 8% of men with prostate cancer have high-grade Gleason scores of 8, 9, and 10.

Getting a Biopsy
The most common prostate biopsy method is transrectal ultrasound-guided biopsy, also known as TRUS. The procedure is typically performed in a urologist's office and takes about 20 minutes. While the patient is lying on his side, an ultrasound probe is inserted into the rectum to visualize the prostate. Fitted to the probe is a special biopsy gun that drives ultra-fine needles (usually about 1/2-inch long and 1/16-inch wide) through the wall of the rectum and into the prostate. In less than a second, the hollow needle removes a small tissue sample called a core. Usually, 8 to 12 tissue samples (cores) are taken from the right and left side of the gland and at the back of the outer peripheral zone of the prostate. It is here, extending along the sides like a shallow horseshoe, that most cancers are found.

After the procedure, the tissue samples are sent to a medical laboratory to be examined by a pathologist. The results are usually ready in three to five days. Nearly 75% of the time, no prostate cancer is detected in the samples, generally because the elevated PSA levels that prompted the biopsy were due to another prostate condition (such as BPH or prostatitis) or a nonmedical reason (such as recent sexual activity).

Many men worry that prostate biopsy will be painful, but the exam usually causes only minor discomfort, provided they are done properly. A local anesthetic is used by many urologists to numb the area and diminish any possible pain symptoms. Antibiotics are necessary to reduce risk of sepsis. Also, it's important not to be taking aspirin or blood thinners before the biopsy to avoid risk of bleeding.

Common biopsy side effects may include minor rectal bleeding; blood in the stool, urine, or semen; and soreness in the biopsied area. All of these side effects disappear over time. Sometimes bleeding can be severe and may require treatment in the immediate follow- up period, so someone who has a biopsy should be sure they have the doctor's contact number should problems develop.

Rendering a Definitive Diagnosis
Looking at and diagnosing limited prostate cancer on biopsy is one of the most difficult diagnoses in pathology. For starters, prostate cancer is often very tiny on a needle biopsy.

While some other cancers in the body are obvious in terms of their malignancy and how they appear under the microscope, the findings of malignant prostate cancer tend to be extremely subtle. Put these factors together and you can end up with problems interpreting the slides, with both under-diagnosis and over-diagnosis as possible outcomes.

The problem with under-diagnosis relates to the limited cancer and subtle findings in the sample. Problems with over-diagnosis relate to a lot of mimickers of prostate cancer that are viewed under the microscope. These benign cells closely resemble prostate cancer. Add an inexperienced pathologist to the mix and the results can be greatly skewed.

The biggest mistake made by a pathologist is calling something cancer when it's benign— and that happens anywhere from 1.3 to 1.5% of the time each year. That may not seem like a lot, but when you think that such a grave error can lead a man to undergo

Mistakes are also made in the grade (Gleason score) of the cancer, which could ultimately influence decision making, ranging from surgery versus radiation, and the type of radiation used. About 20% of the time, there is a significant change in the grade following a second opinion of the biopsy sample.

Differences of opinion come when pathologists say they really don't know what they are seeing under the microscope. This finding is called suspicious of cancer. This diagnosis is given about 5% of the time. However, when those biopsy samples are sent to Johns Hopkins for a second opinion, the pathologist ends up agreeing with the original suspicious label about 30% of the time. The other 70% of the time the sample is called definitively cancer or definitively benign.

Your Pathology Report
It is recommended that you obtain a copy of your pathology report from your urologist.

This is your medical information and you have every right to have it. Take the time to find out what the report means, and don't be scared by the findings. Currently, it's estimated that only about half of the men get a hold of their reports.

Once you have the report, confer with your doctor, and go over the salient points with him While the urologist should tell his patient what is on the report, some just don't take the time.

Insist that your urologist explain the findings of your pathology report to you. Now that you know what's involved in diagnosing prostate cancer, you are ready for Key #2 — soliciting other opinions to help make your treatment decision.

KEY 2 is titled: Get A Second (and Third or Fourth) Opinion about Your Prostate Cancer Diagnosis and Prostate Cancer Treatment

Visit this link to get a downloadable PDF copy of the full special report:

7 Keys to Treating Prostate Cancer

Johns Hopkins Health Alerts | Prostate Disorders | Understand Your Prostate Biopsy: Key 1

Seven Keys to Treating Prostate Cancer: Introduction

Sun, 22 Jul 2007 09:20:34 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Seven Keys to Treating Prostate Cancer: Introduction

7 Keys to Treating Prostate Cancer

Introduction

If you have received a diagnosis of prostate cancer, you are far from alone. Prostate cancer is the second most common form of cancer in men (after skin cancer) and the third most common cause of cancer death (after lung cancer and colon cancer). An American boy born today has a 16% chance of developing prostate cancer and about a 3% risk of dying from it.

Prostate cancer may progress so slowly that some patients live with it for years and end up dying of something else; however, once it spreads to the bones it is often incurable. The American Cancer Society estimates that there will be about 232,000 new cases of prostate cancer in the United States in 2007, with about 30,000 men dying from the disease this year.

The good news is that reliable diagnostic tests and numerous treatment options are available for prostate cancer, and death rates from prostate cancer are on the decline. Moreover, most prostate cancer is slow growing, so usually you can give yourself time to learn about and carefully weigh all the options available to treat prostate cancer. And it's important that you take the time to do so. Of all the cancers, cancer of the prostate is unusual in that there is no consensus among doctors about the best treatment, or even whether any type of treatment is absolutely necessary.

Of course, you will make final decisions about your treatment with your doctor. You should talk to your doctor about the relative risks and benefits of each treatment and consider consulting physicians from different fields to get a broader spectrum of opinion. The information presented here will provide you with the most crucial issues to consider in treating your prostate cancer and the important questions to ask your doctor.

Table of Contents

Key One: Understand Your Prostate Biopsy
Key Two: Get A Second (and Third or Fourth) Opinion about your Prostate Cancer Diagnosis and Prostate Cancer Treatment
Key Three: Choose the Right Treatment for Your Prostate Cancer
Key Four: Restore and Maintain Erectile Performance
Key Five: Seek Extra Help—If Needed
Key Six: Understand the Role of Diet
Key Seven: Consider Complementary Therapies

Read on: Key #1: Understand Your Prostate Biopsy==>

Johns Hopkins Health Alerts | Prostate Disorders | Seven Keys to Treating Prostate Cancer: Introduction

A Better Blood Test For Prostate Cancer

Thu, 07 Jun 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Better Blood Test For Prostate Cancer

This article on EPCA-2 testing for prostate cancer comes from a recent Johns Hopkins Medicine Press Release.

New studies of a blood protein recently identified at Johns Hopkins, early prostate cancer antigen-2 (EPCA-2), may change the way men are screened for prostate cancer -- a disease that kills over 27,000 men every year.

Current standards of screening and testing for prostate cancer focus on the blood protein prostate-specific antigen (PSA) along with a digital rectal examination. Men who have more than 2.5 nanograms per milliliter of PSA are considered at risk for prostate cancer.

However, PSA testing often erroneously highlights noncancerous conditions (false positives) and can miss some cases of prostate cancer (false negatives), according to Robert H. Getzenberg, Ph.D., professor of urology and director of research at the James Buchanan Brady Urological Institute at The Johns Hopkins University School of Medicine.

Due to elevated PSA levels, approximately 1.6 million men undergo prostatic biopsies in the United States annually, and roughly 80 percent of these men have negative results, according to Dr. Getzenberg, lead author of the study. He says that of the entire population of men in the United States who have been tested for PSA, an estimated 25 million have elevated PSA levels, yet a biopsy of the prostate that did not reveal any prostate cancer. Conversely, roughly 15 percent of men with prostate cancer go undetected because their PSA levels are below the cutoff level, according to Getzenberg.

In a study published in the April 2007 issue of the journal Urology, Getzenberg and a team of Hopkins researchers introduce evidence in support of EPCA-2 testing as a more accurate way to identify prostate cancer within the prostate.

“A blood test based on EPCA-2 may greatly improve our ability to accurately detect prostate cancer early and minimize the number of false positives, therefore lowering the number of unnecessary biopsies,” says Getzenberg. “In addition, this is the first time we have a test that effectively distinguishes between men with cancer confined to the prostate and those whose prostate cancer has spread outside of the gland.”

Getzenberg and his team measured EPCA-2 levels in the blood of 330 Hopkins patients separated into several groups: men with normal PSA levels and no evidence of prostate cancer; men with elevated PSA levels but who had negative biopsies, men with a common noncancerous prostate condition known as benign prostatic hypertrophy (BPH) who did not receive biopsies for prostate cancer, men with prostate cancer but with normal PSA levels, men with prostate cancer confined to the prostate, men with prostate cancer that had invaded outside of the gland at the time of surgery, and a diverse group of patients with benign conditions of other organs as well as individuals with other cancer types.

Patients with an EPCA-2 cutoff level of 30 nanograms per milliliters or higher were considered to be at risk for prostate cancer. This cutoff was based on a pilot study of 30 blood samples, which was then applied throughout the larger study.

Results showed that the EPCA-2 test was negative in 97 percent of the patients who did not have prostate cancer. Men with no evidence of prostate cancer (regardless of their PSA levels), as well as the control group of patients with other cancer types and benign conditions, all had EPCA-2 levels below the cutoff.

In contrast, in a multi-institutional study published in 2003 in the Journal of Urology, PSA levels between 4 and 10 nanograms per milliliter were shown to be accurate in identifying patients without prostate cancer only 19 percent of the time.

In addition, 77 percent of the BPH patients had a level of EPCA-2 lower than the cutoff point. Getzenberg says this is well within the likely percentage range of BPH patients who are prostate-cancer free. He says this result was encouraging since BPH is often associated with elevated PSA levels, leading to misdiagnosis and unnecessary biopsies.

When it came to correctly identifying patients with prostate cancer, EPCA-2 levels at or above the cutoff were detected in 90 percent of the men with organ-confined prostate cancer and in 98 percent of the men with disease outside the prostate. Overall, in this study, the EPCA-2 test detected 94 percent of the men with prostate cancer.

Results of the study also revealed that EPCA-2 levels were significantly higher in patients whose prostate cancers had spread outside the prostate compared to those with disease confided to the gland. EPCA-2 was dramatically better at separating these groups than were PSA levels, according to Getzenberg.

“This is important, since prostate cancer that has spread outside the prostate is more deadly, which makes it even more crucial to have a tool that detects it early,” says Getzenberg.

An optimized version of the assay, evaluated in a separate set of 55 patients, supported the earlier findings. Finally, the EPCA-2 test identified 78 percent of the men with prostate cancer in the group with PSA levels below the accepted cutoff level of 2.5 nanograms per milliliter. According to their PSA levels, these were all "healthy men," but EPCA-2 was able to show that they had prostate cancer.

EPCA-2 is the second prostate-cancer marker identified by Getzenberg and his team that has outperformed PSA. Last year, they discovered an unrelated, tissue-based test, EPCA-1, that also proved effective at identifying prostate cancer. The only commonality between these markers is that they were discovered using the same approach. Getzenberg says the efficacy of EPCA-1 as a test of biopsy samples is currently being evaluated.

Getzenberg says larger clinical trials for EPCA-2 are planned that could make this test available to the public in approximately 18 months.

VIDEO PRESS RELEASE:

For a video of Dr. Getzenberg discussing EPCA-2 and prostate cancer diagnosis, please click on this link:
EPCA-2 and Prostate Cancer video: PLAY
(File size is 10MB, so viewed best with a high-speed internet connection, or right-mouse button click to download file to your computer, and view from there)

Funding for the study was provided by the National Cancer Institute of the National Institutes of Health, and Onconome Inc. Under a licensing agreement between Onconome Inc. and the University of Pittsburgh, Getzenberg is entitled to a share of royalty received by the University on sales of products described in this manuscript. Getzenberg also is a paid consultant to Onconome Inc., which has a licensing agreement with The Johns Hopkins University covering EPCA-2 and related technologies. The terms of this arrangement are being managed by The Johns Hopkins University in accordance with its conflict of interest policies.

Other researchers from the James Buchanan Brady Urology Institute at Johns Hopkins who contributed to this study are Eddy S. Leman, Ph.D.; Department of Urology Chairman Alan W. Partin, M.D., Ph.D.; Daniel W. Chan, Ph.D.; Bruce J. Trock, Ph.D.; Lori J. Sokoll, Ph.D.; Leslie Mangold, and Grant W. Cannon.

Johns Hopkins Health Alerts | Prostate Disorders | Better Blood Test For Prostate Cancer

Your PSA Questions Answered

Thu, 28 Jun 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Your PSA Questions Answered

Is the free PSA a helpful diagnostic tool? When should a man have his first PSA test? Johns Hopkins urologist, Jacek L. Mostwin M.D. answers.

On the first PSA test:

Q. I am 56 years old and just had surgery for my prostate cancer (5.5 ng/ml, Gleason 6). Everything went fine. I amazed my doctor by going surfing less than a month after the surgery. My question, however, has to do with my son, who is now 30 years old. When should he have his first PSA test?
From a Prostate Bulletin subscriber in Santa Monica, CA

A. There are no universally accepted standards for these recommendations, although experts who have studied familial patterns of prostate cancer inheritance have recommended that members of primary affected relatives (brothers, fathers, sons) begin testing at age 40. The general recommendations of the American Urological Association are to begin PSA testing at age 50 for men in whom there is no family history, and to begin PSA testing at 40 for those with family histories.

We have on occasion seen sons of our patients come in with moderately advanced disease at age 40, so even this age is open to question. There is little harm in obtaining the first PSA as early as desired, then, assuming the value is no higher than the averages for that age group -- say, 0.6 ng/ml for a 35-year-old man -- follow the progress every few years. A gradual increase in PSA velocity suggests early development of the disease.

On the free PSA test:

Q. When you examine a patient, do you make use of free PSA in your diagnosis for prostate cancer, or do you go by PSA alone?
From a Prostate Bulletin subscriber in Bagnell, MO

A. Free PSA (or fPSA) can be a helpful aid in interpreting the significance of a PSA value between 4.0 and 10.0 ng/ml, the range in which 25% of men undergoing biopsy are found to have prostate cancer. In general, the free PSA is inversely proportional to the likelihood and the volume of prostate cancer in this group, but the value is not now commonly used in guiding clinical decisions. In an older man in whom a very large prostate is associated with a higher PSA value, a very high free PSA is more suggestive of benign growth, but the values are no longer used with as much conviction as they were only a few years ago.

Free PSA is being replaced by PSA velocity as a better indicator of the likelihood of a man’s harboring an undiagnosed prostate cancer. These super-refinements of PSA interpretations continue to change. There is little substitute for the prostate biopsy in determining the presence or absence of prostate cancer. However, once prostate biopsies have been done, changes in free PSA may help to guide management recommendations, such as for watchful waiting or repeat biopsies.

Johns Hopkins Health Alerts | Prostate Disorders | Your PSA Questions Answered

Proton Beam Therapy

Thu, 17 May 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Proton Beam Therapy

If you have prostate cancer, should you consider proton beam therapy? Dr. Jack Mostwin, Medical Editor of the Johns Hopkins Prostate Bulletin, offers his insights.

Q. Even though I have been told that the radical prostatectomy offers the best chance for a cure of my prostate cancer, I am put off by potential side effects from the surgery, erectile dysfunction in particular. At my prostate cancer support meeting last night, I spoke with a man who traveled to California last year to have his prostate cancer treated with proton beam radiation. Not only did he not suffer any side effects, but his doctor told him that he is cured of his prostate cancer. Is there any good evidence that this therapy is something I should consider as a viable treatment option?

From a Prostate Bulletin subscriber in Lake Havasu City, AZ

A. There are only a few centers offering proton beam radiotherapy in the United States: Loma Linda University in California pioneered the application of the technique to prostate cancer, and Harvard University has used it for neurosurgical problems as well as prostate cancer. Other proton beam centers in the United States include The Proton Therapy Center at the University of Texas M.D. Anderson Cancer Center in Houston, TX; the Midwest Proton Radiotherapy Institute in Bloomington, IN; and the University of Florida Proton Therapy Institute in Jacksonville, FL.

More precision is claimed for this form of beam than other forms. Because of reduced scatter of the proton beam, a higher dosage of radiation can be administered in a precise way to the tumor or targeted structure. Higher conformal beam radiation doses are thought to be more effective against cancer, and the reduced scatter of the proton beam will also reduce local side effects and reduce the possibilities of local recurrence.

I spoke to my friend and colleague, Dr. Theodore DeWeese, before completing the answer to this question. Dr. DeWeese is the director of Radiation Oncology at Hopkins, with extensive clinical and experimental work in radiation and prostate cancer. He had just returned from a meeting at which he discussed the very issues brought up in your question. Here are some of the things we discussed.

In the September 14, 2005 issue of the Journal of the American Medical Association, researchers from the Massachusetts General Hospital in Boston (Harvard System) reported on two groups of 393 (total) prostate cancer patients treated with conventional (70.2 Gy, pronounced “Gray”) or higher dose (79.2 Gy) therapy delivered by photon (a quantum of electromagnetic energy) and proton beam therapy. Five years after treatment, the proportion of men free of PSA recurrence was 61.4% after conventional therapy, 80.4% for high-dose therapy. The researchers did not report any difference on overall death rate from prostate cancer, and the difference in side effects was minimal.

However, rectal toxicity in higher-grade tumors undergoing high dose therapy was 17%, much higher than standard IMRT (intensity-modulated radiation therapy). The most recent studies comparing proton beam to IMRT have suggested comparable responses, but the questions about greater rectal toxicity in proton beam therapy leave some concerns still to be addressed.

Johns Hopkins Health Alerts | Prostate Disorders | Proton Beam Therapy

PSA Terminology Explained

Thu, 26 Apr 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Prostate Disorders | PSA Terminology Explained

PSA density … PSA velocity … what does it all mean? Jack L. Mostwin, M.D., professor of urology at Johns Hopkins explains these important terms.

All men, aged 40 or so, undergo PSA (prostate-specific antigen) testing to screen them for prostate cancer. PSA is an enzyme produced almost exclusively by the glandular cells of the prostate and normally only very small amounts of PSA are present in the blood. High levels of PSA can indicate prostate problems, including BPH and prostate cancer. But high PSA levels can also be caused by a variety of daily activities. Recently, researchers have developed several ways to improve the PSA test’s accuracy. These improvements include:

PSA density -- assessing PSA level in relation to prostate size

PSA density takes the size of a man’s prostate into account when evaluating his PSA level. It is calculated by dividing the PSA value by the size of the prostate (as determined by transrectal ultrasound). This measurement helps doctors distinguish between BPH and prostate cancer: The higher the PSA density, the greater the chance of cancer, because the elevated PSA level is less likely to be the result of daily activities or benign prostate enlargement.

According to several studies, a PSA density greater than 0.15 indicates a higher risk of cancer. PSA density appears most useful in diagnosing prostate cancer in men with PSA levels between 4 ng/ml and 10 ng/ml.

PSA velocity—monitoring annual changes in PSA velocity

This measurement takes into account annual changes in PSA values, which rise more rapidly in men with prostate cancer than in men without the disease. PSA velocity is especially helpful in detecting early cancer in men with mildly elevated PSA levels and a normal digital rectal exam. It is most useful in predicting the presence of cancer when changes in PSA are evaluated over at least one to two years.

Percent PSA—measuring the ratio of free to total PSA (percent free PSA or complexed PSA)

PSA in the blood is either bound (attached to proteins) or unbound (free). PSA assays usually measure the total PSA (both free and complexed). Other assays measure the percentage of free PSA or the percentage of complexed PSA.

Compared to men with BPH, men with prostate cancer have a higher percentage of bound PSA and a lower percentage of free PSA. Research suggests that determining the ratio of free to total PSA in the blood helps distinguish between PSA elevations due to cancer and those caused by BPH.

Age-specific PSA—adjusting the PSA result for a patient’s age. PSA increases with age because the prostate gradually enlarges as men grow older. Some years ago, researchers suggested adjusting PSA levels to the age of the patient: Higher levels would be considered normal in older men, and lower levels considered normal in younger men. However, there is concern that the use of higher PSA thresholds in older men will miss important cancers. As noted above, physicians should suspect the presence of prostate cancer when levels are above 2.5 ng/ml in men in their 40s.

Johns Hopkins Health Alerts | Prostate Disorders | PSA Terminology Explained

News on BPH from Johns Hopkins

Thu, 22 Feb 2007 06:00:00 CST

Johns Hopkins Health Alerts | Prostate Disorders | News on BPH

Severe form of "enlarged prostate" disease discovered by a team of Johns Hopkins researchers.

FEBRUARY 2007 PRESS RELEASE

Researchers at Johns Hopkins reported finding substantially higher levels of a protein made by a gene known as JM-27 in men whose BPH is more severe and more likely to lead to bladder-related complications if left untreated. The study was published in the February 2007 issue of the Journal of Urology.

Millions of middle-aged and older men experience the symptoms of an enlarged prostate multiple times during the day and night. What they may not know is that the disease known as BPH (benign prostatic hyperplasia), marked by urgency and frequent urination, is not one but at least a pair of disorders, and that one of the pair -- tied to a newly identified gene -- has far more serious implications.

Although BPH affects the prostate, the resulting symptoms are often called "lower urinary tract symptoms," or LUTS. These symptoms reflect not only the direct effects of the prostate on urinary flow and urgency, but functional changes in the bladder that result from the increased pressure.

The Hopkins team, lead by Robert Getzenberg, Ph.D., also developed a blood test that detects the JM-27 protein in men with severe symptoms. The JM-27 diagnostic test, if eventually approved by the FDA, could be used to identify men with this highly symptomatic form of the disease early, before there is any damage to the bladder or urinary tract.

"Our experiments show that the expression of this marker is related to the presence of the severe form of BPH and not to the size of the prostate or to the presence or risk of prostate cancer," says Dr. Getzenberg. "What we’re looking at is two diseases: BPH that produces more mild symptoms and is less likely to lead to bladder and other urinary tract damage, and BPH that is highly symptomatic with increased potential to do damage to the bladder.”

In their latest study, Dr. Getzenberg and his team tested blood samples taken from 85 men. Twenty-nine had either no detectable BPH symptoms or mild ones, 39 experienced more marked symptoms of BPH, and 17 had confirmed prostate cancer.

The blood of all patients was not only screened for the presence of the JM-27 protein, but also analyzed to determine exactly how much JM-27 was in the bloodstream of each man. Researchers found a “statistically significant” difference in the levels of JM-27 in the men who were either completely asymptomatic or had mild symptoms of BPH. Men with higher levels of JM-27 had the less severe form of BPH, whereas men with low levels of JM-27 had the worse form of the disease based on their symptoms. And the presence of prostate cancer did not throw these results off; in other words, even in these men, it could be determined, based on their levels of JM-27, whether they suffered from the mild or severe form of BPH.

Dr. Getzenberg says the new biomarker test detects approximately 90 percent of the men with the severe form of BPH and only incorrectly classifies men as having this form of the disease in 23 percent of the cases.

Current medical therapy for men who suffer from BPH is with two classes of drugs: alpha blockers, which relax the prostate and 5-alpha reductase inhibitors, which help to shrink it. Forms of BPH that do not respond to medical therapies frequently require surgical intervention.

"The next step is to figure out which drugs work best on which form of the disease as differentiated by JM-27,” Dr. Getzenberg says.

The incidence of BPH is estimated to equal the age of the men. Therefore, 50 percent of men in their 50s have the disease, and this increases to 80 percent for those in their 80s.

In the next issue of The Johns Hopkins Prostate Bulletin, Editorial Director, Gerald Secor Couzens interviews Dr. Getzenberg in detail about his new biomarker test to detect the JM-27 protein.

To learn more about The Johns Hopkins Prostate Bulletin, please click on this link.

Johns Hopkins Health Alerts | Prostate Disorders | News on BPH

Saw Palmetto Losing Ground

Thu, 15 Mar 2007 06:00:00 CST

Johns Hopkins Health Alerts | Prostate Disorders | Saw Palmetto Losing Ground

Hopkins professor, Dr. H. Ballentine Carter, reviews the data on saw palmetto for BPH symptoms.

Saw palmetto, otherwise known as serenoa repens and sabal serrulata, is an over-the-counter herbal supplement made from the fruit of the American dwarf palm tree. Its manufacturers claim that saw palmetto can ease the urinary symptoms of an enlarged prostate, or benign prostatic hyperplasia (BPH), faster and with fewer side effects than prescription treatment.

Saw palmetto is touted to help relieve BPH symptoms, including the frequent, urgent need to urinate, a decreased or stop-and-start urine flow, and the feeling that you haven’t completely emptied your bladder.

While many users swear by saw palmetto and some studies have suggested a benefit, other research has found saw palmetto doesn’t help. H. Ballentine Carter, M.D., Professor of Medicine in the Department of Urology at the Johns Hopkins School of Medicine, says he doesn’t often recommend saw palmetto as a treatment for the lower urinary tract symptoms. Dr. Carter believes the mixed results from clinical trials can be explained by differences in study design and among the groups of men that were studied. “The most comprehensive study to date,” says Dr. Carter, “shows that saw palmetto has no benefit over placebo.”

This study, published in The New England Journal of Medicine (NEJM), examined 225 men. The men were randomly assigned either a 160-mg saw palmetto supplement, taken twice daily, or a placebo. After a year, saw palmetto was found to be no more effective than placebo for treating lower urinary tract symptoms. The NEJM study is notable because of its length; many earlier studies were only weeks long.

If you still want to use saw palmetto for BPH, speak with your doctor beforehand and keep in mind that the FDA does not regulate supplement production, so it’s unclear what you’re getting when you buy a saw palmetto product. Side effects of saw palmetto are mild but can include digestive upset and lack of sexual desire. In rare cases, saw palmetto can cause bleeding, so it’s not recommended for men with bleeding disorders, who take anticoagulants such as Coumadin (warfarin), or who are about to undergo surgery. It’s also not a good idea to take saw palmetto in conjunction with a prescription medication for BPH.

Johns Hopkins Health Alerts | Prostate Disorders | Saw Palmetto Losing Ground

Getting an Accurate Diagnosis for Prostatitis

Thu, 01 Feb 2007 06:00:00 CST

Johns Hopkins Health Alerts | Prostate Disorders | Getting an Accurate Diagnosis for Prostatitis

Effective treatment for prostatitis depends on nailing down the diagnosis.

Prostatitis is a broad term for an infection or inflammation of the prostate. Over the past decade, urologists have identified four types of prostatitis:

Acute bacterial prostatitis is a sudden-onset infection that lasts for several days.

Chronic bacterial prostatitis is a recurrent infection that can last for weeks, subside, and then flare-up again.

Chronic non-bacterial prostatitis/chronic pelvic pain syndrome (CPPS) is diagnosed when no infectious organism can be identified.

Asymptomatic inflammatory prostatitis is diagnosed when white blood cells are found in the prostatic secretions or prostate tissue of a man who has no symptoms of prostatitis.

A thorough diagnostic work-up for prostatitis is critical for several reasons. Some symptoms of prostatitis overlap with those of urethritis (inflammation of the urethra), cystitis (inflammation of the bladder), benign prostatic hyperplasia, and prostate cancer, and these conditions must be ruled out. It’s also essential to distinguish between the various types of prostatitis because treatment that is effective for one type may have no effect on another.

Recognizing and accurately reporting your prostatitis symptoms is the first step in obtaining a correct diagnosis. After taking a detailed history of your symptoms, your urologist will conduct a number of diagnostic tests to rule out other conditions and to identify the type of prostatitis you have. Common tests include:

Digital rectal exam (DRE). A digital rectal exam will tell your physician whether the prostate is swollen, tender, warm, and firm (suggesting an acute bacterial infection) or enlarged and either soft or firm (suggesting a chronic bacterial infection). Your physician may also press on the muscles and ligaments supporting the pelvic floor and the perineum to evaluate any discomfort or pain you may have in the area.

Urine analysis. Your urine will be analyzed for the presence of bacteria. If chronic prostatitis is suspected, another urine sample may be collected after prostate massage. The sample will be examined for signs of bacteria or inflammation.

Prostate secretion analysis. A sample of prostate fluid obtained with prostate massage will be examined for signs of infection or inflammation.

Prostate-specific antigen (PSA) test. An elevated PSA level can indicate an inflamed prostate or prostate cancer.

If more information is needed to make a diagnosis, one or more of the following tests may be ordered:

Cystoscopy. A thin, flexible, tubelike viewing device (cystoscope) is passed through the urethra and into the bladder. This allows the physician to examine the urethra, bladder, and prostate for abnormalities.

Urine flow studies. These “voiding” studies evaluate the strength and other characteristics of your urine flow.

Transrectal ultrasound. A narrow ultrasound probe is inserted into the rectum to provide ultrasound images of the prostate.

Prostate biopsy. If the diagnosis remains uncertain, your urologist may want to perform a biopsy of the prostate tissue.

The take-home message on prostatitis diagnosis

Acute bacterial prostatitis is the easiest form of the disease to identify and cure. Chronic non-bacterial prostatitis/ CPPS—the most common type— is the most difficult to treat. With chronic non-bacterial prostatitis/ CPPS especially, the key is to seek the best available medical care, preferably from a urologist with expertise in prostatitis. With an accurate diagnosis, expert care, and perseverance, you should be able to find ways to manage your most difficult symptoms.

Johns Hopkins Health Alerts | Prostate Disorders | Getting an Accurate Diagnosis for Prostatitis

The Inflammation - Prostate Cancer Link

Thu, 11 Jan 2007 06:00:00 CST

Johns Hopkins Health Alerts | Prostate Disorders | The Inflammation - Prostate Cancer Link

Chronic inflammation may promote the development of prostate cancer.

Inflammation is a sign that the immune system is doing its job in protecting us from infectious agents and injuries. But chronic inflammation has been associated with a wide range of diseases. Today scientists know that inflammatory cells produce free radicals—toxic molecules that can damage cells, especially cellular DNA. This type of DNA damage (also called oxidative damage) can cause genetic alterations (mutations) that lead to the uncontrolled cell division that characterizes cancer. Research conducted at Johns Hopkins now suggests a potential pathway by which inflammation may encourage the development of prostate cancer.

Pathologists at Johns Hopkins have found pockets of inflammation in the midst of cancerous prostate cells and abnormal (probably precancerous) cells known as prostatic intraepithelial neoplasia (PIN). Around the areas of inflammation, they discovered something new—groups of cells that look as if they are dying (atrophying) but are actually dividing (proliferating). The Hopkins researchers named these bizarre groups of cells proliferative inflammatory atrophy (PIA) and believe them to be either the very beginning of cancer formation or perhaps a breeding ground for prostate cancer.

These areas containing PIA show high levels of an enzyme called glutathione S-transferase (GST), a critical substance that helps protect DNA from free radical damage. Ultimately, the gene that produces GST becomes inactivated in these areas of inflammation. GST production is halted, and the surrounding cells lose their DNA protection. Gene mutations may result, and the mutated genes may lead to prostate cancer.

The theory is that inflammation—perhaps triggered by chronic infection, in conjunction with dietary or hereditary factors—leads to the DNA damage and the gene mutations that set prostate cancer in motion. Indirect evidence, gathered over many years, supports this inflammation-prostate cancer link. Some population-based studies, for example, have found a lower risk of prostate cancer among men who take inflammation-reducing medications or follow dietary patterns that are less likely to promote inflammation.

Several population-based studies have suggested that men who take non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin, have a lower risk of developing prostate cancer. In one large study of more than 90,000 men participating in the Kaiser Permanente Medical Care program, those who took six aspirin a day had a 24% risk reduction of developing prostate cancer.

Cholesterol-lowering “statin” medications, such as Lipitor (atorvastatin) or Zocor (simvastatin), also have an anti-inflammatory effect. Some research indicates that men who have taken statins for several years are less likely to be diagnosed with advanced prostate cancer. In an analysis conducted by Hopkins researcher Elizabeth Platz, men who took cholesterol-lowering drugs (90% of which were statins) were half as likely to develop advanced prostate cancer as men who had not taken the drugs.

Dietary habits also influence inflammation. The typical American diet— high in saturated fat, sugar, and red meat and low in fiber, fruits, and vegetables—encourages inflammation (not to mention obesity and heart disease). Reducing your intake of saturated fat—found primarily in animal-based products such as meat, poultry, whole milk products, butter, and cheese—and increasing your intake of fruits and vegetables are important first steps to discouraging inflammation and thus reducing your risk of prostate cancer.

Johns Hopkins Health Alerts | Prostate Disorders | The Inflammation - Prostate Cancer Link

Recent Research Spells Good News for Prostate Cancer Patients

Thu, 14 Dec 2006 06:00:00 CST

Johns Hopkins Health Alerts | Prostate Disorders | Prostate Cancer Survival

Strict Diet and Lifestyle Changes May Reduce the Risk of Progression in Early Prostate Cancer

Men with early prostate cancer who follow a strict vegetarian diet, exercise regularly, and practice stress reduction techniques may be able to lower their PSA levels and their risk of cancer progression, according to a study from the Journal of Urology. Researchers wanted to test the ability of a very low-fat diet (10% or less of daily calories) to slow or prevent worsening of early prostate cancer. The diet followed was a variation on the Ornish diet, originally designed by Dean Ornish, M.D., to reduce heart disease risk. The 93 study participants were men with early-stage prostate cancer who had chosen “watchful waiting” instead of active treatment for their prostate cancer. The men were randomly assigned to the Ornish program or to usual care.

During the one-year study, six men in the usual care group underwent conventional treatment because of rising PSA levels (an indication of disease progression) or evidence of progression on magnetic resonance imaging (MRI). In contrast, none of the men in the comprehensive lifestyle group required treatment. PSA levels decreased 4% in the lifestyle group, whereas PSA levels increased 6% in the usual care group. In addition, cell culture studies showed that blood from men in the lifestyle group inhibited the growth of prostate cancer cells by 70%, compared to 9% for men receiving usual care.

Prostate Cancer Diagnosis Usually Does Not Mean Shorter Lifespan

Good news for men diagnosed with prostate cancer from the Journal of Clinical Oncology: The vast majority of men diagnosed with prostate cancer today will live as long as their counterparts who do not have prostate cancer. This is the conclusion from an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) program, a huge national database of cancer statistics.

The researchers examined five- and 10-year survival data for 183,484 men diagnosed with prostate cancer between 1990 and 2000. They found that the overall five-year survival rate for prostate cancer patients was 99%; 10-year survival was 95%. Compared with men in the general population, those with prostate cancer had an excess mortality of only 1% at five years and 5% at 10 years. The researchers noted that two-thirds of the men were diagnosed with well-differentiated or moderately differentiated localized/regional cancers. Among these men, there was no increased mortality compared to men in the general population.

Prostate cancer experts continue to debate whether widespread prostate-specific antigen (PSA) screening is responsible for lower mortality rates. However, most men diagnosed in the PSA era do not experience excess mortality. This finding should be comforting for men who are living with a prostate cancer diagnosis.

Johns Hopkins Health Alerts | Prostate Disorders | Prostate Cancer Survival

Get Your FREE Special Report: 7 Keys to Treating Prostate Cancer

Mon, 11 Sep 2006 12:32:21 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Treating Prostate Cancer

Dear Health Alert Subscriber,

This Johns Hopkins Special Report: 7 Keys to Treating Prostate Cancer, is our gift to you as a registered Health Alert reader, in recognition of Prostate Cancer Awareness Month. We hope you’ll read it and share it with your loved ones.

The American Cancer Society estimates that over 232,000 new cases of prostate cancer will be diagnosed in 2007. More than 30,000 men will die of the disease. The good news is that prostate cancer is preventable -- if you know your options.

That’s why Dr. Jacek Mostwin, Director of Johns Hopkins world-renowned Brady Urological Institute, has prepared this important free Special Report, exclusively for you and our other health alert readers.

7 Keys to Treating Prostate Cancer provides the latest medical research on prostate cancer, its causes and stages. This in-depth 25-page report provides clear, practical advice to help you understand what your PSA test scores mean … and what your options are if you do get a diagnosis of prostate cancer. It outlines the various treatment options, and how to cope with their potential side effects. This free special report also discusses simple lifestyle changes for men which can actually help prevent prostate cancer.

This is information every man should arm himself with in the fight against prostate cancer.

Click here to get your copy of this FREE Johns Hopkins Special Report PDF: 7 Keys to Treating Prostate Cancer

Johns Hopkins Health Alerts | Prostate Disorders | Treating Prostate Cancer

When Watchful Waiting Is the Right Choice for Prostate Cancer

Thu, 14 Sep 2006 06:00:00 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Prostate Cancer and Watchful Waiting

Important information from Johns Hopkins in honor of Prostate Awareness Month.

As a subscriber to Prostate Disorders Health Alerts, you know how important it is to remain vigilant about prostate health. Recently, Dr. H. Ballentine Carter and a team of prominent Johns Hopkins scientists concluded a study on the subject of expectant management and prostate cancer. The study is the subject of an article in our Health After 50 newsletter. Here is the article in its entirety.

When Watchful Waiting Is the Right Choice for Prostate Cancer

Prostate cancer is considered one of the most treatable cancers — detected at an early stage in up to 80% of cases, often slow growing, and typically curable if it is diagnosed before it has spread outside the prostate gland. In fact, some tumors may never become life threatening, even without treatment. Yet because physicians can’t tell which prostate cancers will be aggressive and prone to spread, a certain number of men are treated unnecessarily for prostate cancers that might not have posed significant health risks.

Expectant management, also called watchful waiting, involves delaying surgery or radiation along with regular monitoring of the man’s condition. And it is a treatment option for men with less aggressive prostate cancer; however, doctors and patients are often reluctant to opt for it, afraid of losing the opportunity for cure by allowing the prostate cancer time to spread.

But a recent study at Johns Hopkins has discovered that for some men newly diagnosed with prostate cancer, watchful waiting may not compromise the opportunity for a cure. The study, which looked at men enrolled in the university’s expectant management program from 1995 to 2005, has researchers optimistic about the use of watchful waiting for a select group of low-risk prostate cancer patients.

H. Ballentine Carter, M.D., Professor of Urology and Oncology at the Johns Hopkins School of Medicine and lead author of the study, estimates that overall, perhaps 30% of newly diagnosed men could be managed with watchful waiting.

Who Is a Candidate?

In general, expectant management is considered an option for small, low-grade cancers. Staging determines the size of the tumor and how far it has spread. T1 tumors are confined to the prostate and are too small to be felt during a digital rectal exam (DRE). The T1 stage is divided into three smaller stages. T1c tumors are the most common stage today. They include those tumors detected through prostate-specific antigen (PSA) testing. (T1a and T1b tumors are found incidentally, rather than through PSA testing.)

Cancer grade, or Gleason score, describes how aggressive the cancer appears to be. All of the men who delayed surgery in the Hopkins’ study had:

stage T1c cancer;

a Gleason score of 6 or less;

a PSA density of 0.15 or less;

cancer presence in no more than two cores (tissue samples taken during a biopsy);

no more than 50% of any core involved with cancer.

In the results, published in the Journal of the National Cancer Institute, 38 patients who delayed surgery for up to two years showed no greater risk of incurable cancer than 150 similar patients who had surgery immediately after their diagnosis.

Says Dr. Carter, “I believe the most appropriate candidates for expectant management at this point are those with the features above. For men who have a limited life expectancy, expectant management may be appropriate for some men with stage T2 disease [the tumor can be felt during DRE].”

Beyond Grades and Stages

Age is an important consideration in watchful waiting. Delaying treatment for prostate cancer is certainly least risky for men over 70 with small tumors; most, Dr. Carter feels, will not benefit from intervention. In fact, in some watchful waiting programs, men over the age of 75 are regularly monitored but go without annual biopsies.

Younger men, however, are likely to live long enough for their prostate cancers to become life threatening. “Men younger than 65 are at greater risk with watchful waiting, and for most we don’t encourage it,” says Dr. Carter. “However, if a younger man chooses this approach, we respect his decisions and monitor him as carefully as possible.”

The other key factor is the patient’s own comfort level. The decision to choose watchful waiting is often a difficult one. For some men, the knowledge that they have prostate cancer—and a curable form of it, no less—makes watchful waiting seem unbearable: Without treatment, they feel, they would simply be too anxious about the disease worsening or about the possibility of losing the opportunity for cure. For others, the idea of delaying the possible after effects of surgery or radiation (such as impotence or incontinence), coupled with the reassurance of frequent monitoring, makes it worthwhile to wait.

When to Stop Waiting

Some men who choose watchful waiting will go on to require more aggressive treatment. Therefore, patients are strictly monitored with an eye to changes that prompt more aggressive intervention. Monitoring includes semiannual DREs, semiannual screenings of both total and free PSA, and annual prostate biopsies.

Signals to move on to surgery or radiation include a change in PSA velocity (the speed with which PSA levels rise), biopsy results showing a Gleason score of 7 or more, more than two core samples involved with cancer, or more than 50% of any one sample involved. Any of these changes suggest that the prostate cancer has become more aggressive or has spread. Between monitoring tests, any change in the patient’s condition—such as blood in the urine, difficulty urinating, or new pain—also signals a need for intervention. In addition, patients themselves sometimes decide that they no longer wish to wait and request treatment.

In the Future

Dr. Carter’s team is studying tissue samples from their patients, looking at a number of factors—biomarkers, genetic influences, and lifestyle considerations—to determine what puts patients at risk for more aggressive disease during expectant management. The hope, says Dr. Carter, “is that research will reveal a group of biomarkers that doctors can look at to predict disease progression when the disease is still curable.”

Johns Hopkins Health Alerts | Prostate Disorders | Prostate Cancer and Watchful Waiting

What's Your Prostate Symptom Score?

Wed, 11 Oct 2006 09:33:44 CDT

Johns Hopkins Health Alerts | Prostate Disorders | What's Your Prostate Symptom Score

Here’s an easy way to calculate whether you need treatment for benign prostatic hyperplasia (BPH).

The International Prostate Symptom Score questionnaire (see below) was developed by the American Urological Association to help men evaluate the severity of their symptoms from benign prostatic hyperplasia (BPH). This self-administered test can help determine which type of prostate treatment is needed, if any.

Instructions: Use this key to answer each question, then tabulate your score to assess your BPH severity.

Not at all = 0
Less than 1 time in 5 = 1
Less than half the time = 2
About half the time = 3
More than half the time = 4
Almost always = 5

Over the past month, how often have you had the sensation of not emptying your bladder completely after you finished urinating?

Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

Over the past month, how often have you found you stopped and started again several times when you urinated?

Over the past month, how often have you found it difficult to postpone urination?

Over the past month, how often have you had a weak urinary stream?

Over the past month, how often have you had to push or strain to begin urination?

Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

Use your total score to assess BPH severity: mild BPH (1 to 7), moderate BPH (8 to 19), or severe BPH (20 to 35). Generally, no treatment is needed if symptoms are mild; moderate symptoms usually call for some form of BPH treatment; and severe symptoms indicate that surgery for BPH is most likely to be effective.

Johns Hopkins Health Alerts | Prostate Disorders | What's Your Prostate Symptom Score

What to Expect from a Prostate Biopsy

Tue, 14 Nov 2006 06:00:00 CST

Johns Hopkins Health Alerts | Prostate Disorders | Prostate Biopsy

If you're facing a prostate biopsy, it's natural to be apprehensive. Here's a realistic guide to this commonly-performed procedure.

An abnormal prostate-specific antigen (PSA) test provides an important clue to your prostate health. But it cannot determine with certainty whether you have prostate cancer. Until more sophisticated tests are developed, a biopsy of the prostate -- though not perfect -- is the best way to find out whether a high PSA level indicates cancer.

About 800,000 prostate biopsies are performed in the U.S. each year. Known formally as transrectal ultrasound-guided biopsy, prostate biopsy is an in-office procedure that takes about 15 minutes to perform. Despite its reputation as a very painful procedure, a prostate biopsy can be performed with minimal to moderate pain through the use of lidocaine, a local anesthetic. Lidocaine gel can be applied inside the rectum, or the anesthetic can be injected through the rectal wall to numb the nerves around the prostate. Some urologists also may give a mild sedative before the procedure. Good pain control not only keeps you comfortable during the prostate biopsy, but it also helps ensure that the proper number of samples can be taken.

You will be advised to discontinue blood-thinning medications like aspirin, Coumadin (warfarin), or Plavix (clopidogrel) seven-10 days before the prostate biopsy to help prevent excess bleeding after the procedure. If you take vitamin E, fish oil, ginkgo biloba, or other dietary supplements with blood-thinning effects, be sure to let your doctor know. He or she may recommend that you stop taking those as well.

Because the prostate biopsy usually is taken through the wall of the rectum, an enema is required the day of the procedure to clean out the intestines and reduce the risk of fecal contamination and infection. As an extra precaution against infection, most doctors also prescribe an antibiotic to be taken before and after the prostate biopsy.

During the prostate biopsy, you will be asked to lie on your side, with your knees pulled toward your chest. A thin ultrasound probe is inserted into the rectum. The probe emits sound waves that are converted into video images of the prostate. These images are used to guide the lidocaine injection (if one is used) and to position the biopsy device. The spring-loaded biopsy “gun,” with its hollow, ultra-thin needle, is mounted on the ultrasound probe. The biopsy device is directed at varied areas of the prostate, removing a thin (1/16 of an inch) column of prostate tissue (called a core) with each split-second firing through the rectal wall. At least 10-12 cores should be taken and sent to the pathologist for evaluation.

You may experience minor rectal bleeding, or see blood in your stool or urine for a few days. Small amounts of blood in your semen may give it a pinkish tinge for several weeks.

Bear in mind that infection is rare but serious. Call your doctor if you experience any symptoms of infection: fever, painful urination, or discharge from the penis. You also should call your doctor if you experience heavy or prolonged bleeding; significant pain, swelling, or redness near the biopsied area; or difficulty in urinating.

Johns Hopkins Health Alerts | Prostate Disorders | Prostate Biopsy

Why Do So Many Men Develop Prostatitis?

Tue, 15 Aug 2006 15:38:22 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Symptoms and Causes of Prostatitis

Chronic prostatitis usually affects men in their early 40s, and it is one of the leading reasons why men visit a urologist.

Prostatitis is a common condition in which the prostate becomes infected or inflamed, causing severe pain in the perineum -- the area between the rectum and scrotum. Men may also feel pain in their groin, genitals, and lower back. Another possible symptom of prostatitis is an urgent or frequent need to urinate, which can be mistaken for benign prostatic hyperplasia (BPH). Some men complain of painful ejaculation, while others say that ejaculation provides pain relief. According to one study, men with prostatitis have a diminished quality of life that is on par with those who have recently suffered a heart attack.

Prostatitis is often difficult to treat, and part of the problem is that the disease comes in several forms. Some prostatitis patients experience acute flare-ups, with sudden and continuous pain that lasts for several days. More common, however, is chronic prostatitis, which may last for several weeks, only to disappear and then start up again. It usually affects men in their early 40s, and it is one of the leading reasons why men visit a urologist.

Prostatitis is further differentiated by bacterial and nonbacterial causes. Nearly 95% of patients are thought to develop prostatitis from nonbacterial causes, which have yet to be identified. In addition, some men have signs of inflammation, such as white blood cells in their semen, but none of the painful symptoms of prostatitis. A related condition, called prostatodynia, causes the same symptoms as prostatitis, but with no signs of infection or inflammation on laboratory tests.

The causes of prostatitis are often hard to pin down

While the causes of bacterial prostatitis are obvious and easy to detect, researchers are unsure why men develop the more prevalent, nonbacterial form. Some men find that stress, emotional problems, or even coffee may trigger flare-ups. Other possible culprits include zinc deficiency, tight urinary sphincter muscles, infrequent ejaculation, and dehydration.

Some experts suggest that nonbacterial prostatatis is not really a prostate problem at all. Rather, flare-ups could be the result of a pelvic muscle spasm or some other cause that mimics symptoms originating in the prostate. Another theory under investigation is that prostatitis is caused by an autoimmune disorder, in which the immune system mistakenly attacks healthy prostate tissue and promotes inflammation -- not unlike the way rheumatoid arthritis targets the joints. Indeed, researchers recently found that men with chronic prostatitis had increased levels of the same pro-inflammatory molecules that are elevated in the joint tissue of people with rheumatoid arthritis.

What to do

Treatment is fairly straightforward for bacterial prostatitis. A patient is given antibiotics for a period of 4 to 16 weeks. Appropriate antibiotics include carbenicillin (Geocillin), trimethoprim/sulfamethoxazole (Bactrim ), doxycycline (Doryx), fluoroquinolones like ciprofloxacin (Cipro), and others. Bacterial prostatitis is the most curable form of the disease, although some patients may not respond to treatment, or symptoms may reappear once the antibiotics are stopped.

Treatment of nonbacterial prostatitis is more difficult, and no one treatment has been proven to improve symptoms for most men. It may take some trial and error to find a combination of therapies and self-care techniques to obtain symptom relief. While antibiotics typically are reserved only for bacterial diseases, many patients with nonbacterial prostatitis receive antibiotics and a prostate massage, followed by high doses of alpha-blocker drugs (typically used for BPH). Emerging evidence suggests that exercise may improve symtoms. Some men have reported symptom improvement with the 5-alpha-reductase inhibitor finasteride (Proscar), expecially if they also have BPH.

Many men are frustrated because no therapy exists that provides consistent relief from nonbacterial prostatitis. Fortunately, major research efforts are currently under way, such as the NIH-funded Chronic Prostatitis Cohort Study. Experts are optimistic that this study and other research will provide important new insights on improving the management of chronic prostatitis.

Related Prostate Articles:

Diagnosing Prostate Disease:

Prostate Health Alert: The Digital Rectal Examination (DRE)--Do NOT Skip It

PSA (Prostate Specific Antigen): PSA Testing and PSA Levels/Gleason Scores: (PSA Velocity, PSA density)

Prostate Cancer:

Prostate Alert: Can Diet Reduce Your Risk of Prostate Cancer?

Benign Prostatic Hyperplasia (BPH):

BPH Report: Minimally Invasive Treatments for BPH (TUNA and TUMT compared with TURP)

BPH Report: Using Saw Palmetto and Other Herbs to Treat BPH

BPH Alert: Treating BPH – One Option Is Watchful Waiting

Prostatitis:
(acute prostatitis, chronic prostatitis, bacterial prostatitis, non-bacterial prostatitis, prostatodynia)

Prostate Alert: Why Do So Many Men Develop Prostatitis?

Prostate Health Issues:

Prostate Health Issues Report: Finding Help for Sexual Function Problems After BPH Treatment

Prostate Health Issues Alert: Before You Give Up on Viagra

Johns Hopkins Symptoms and Remedies on Prostate Disorders:

Benign Prostatic Hyperplasia (BPH)

Erectile Dysfunction

Prostate Cancer

Johns Hopkins Prostate Disorders

The Johns Hopkins Prostate Disorders Health Alerts material is developed from our monthly newsletter Johns Hopkins Medical Letter: Health After 50, and the Johns Hopkins Prostate Disorders publications, The Johns Hopkins White Papers: Prostate Disorders, and The Johns Hopkins Prostate Bulletin.

Can Diet Reduce Your Risk of Prostate Cancer?

Wed, 14 Jun 2006 14:18:42 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Dietary Fat and Prostate Cancer

A high intake of vegetables may lower the risk of prostate cancer.

The majority of studies on the relationship between dietary fat and prostate cancer have found that a higher fat intake is associated with an increased risk of prostate cancer. Fat makes up 30% to 40% of the calories in the American diet, compared with 15% in Japan. These differences in fat intake may help explain the much lower death rate from prostate cancer in Japan, as well as the great variability in mortality rates around the world. Another possibility is that people who eat a high-fat diet are less likely to eat healthful foods such as vegetables.

A high intake of vegetables may lower the risk of prostate cancer. According to a study published in the Journal of the National Cancer Institute, men who ate 28 or more servings of vegetables a week had a 35% lower risk of prostate cancer than those who ate 14 or fewer servings per week.

Cruciferous vegetables, such as cabbage and broccoli, appeared to provide a further protective effect against prostate cancer: Men who ate three or more servings of cruciferous vegetables a week (in addition to other vegetables) had a 41% lower risk of prostate cancer than those who ate less than one serving a week. Cruciferous vegetables are rich in substances that induce enzymes to detoxify environmental carcinogens, including the free radicals found in the human diet.

Moderate evidence suggests that other dietary components also may help prevent prostate cancer. High intakes of lycopene (an antioxidant found in tomatoes and tomato-based products) are associated with a 16% to 21% reduced risk of prostate cancer. Taking supplements of selenium (a trace element) reduced the risk of prostate cancer by 66% in one study, and another study found that the incidence of prostate cancer was reduced by 34% in men taking vitamin E supplements.

Johns Hopkins Health Alerts | Prostate Disorders | Dietary Fat and Prostate Cancer

The DRE -- Don't Skip It

Fri, 14 Jul 2006 14:13:56 CDT

Johns Hopkins Health Alerts | Prostate Disorders | DRE Test for Prostate Cancer

The DRE exam is an essential screening tool for prostate cancer.

Because the prostate gland cannot be seen or felt externally, your doctor will regularly perform a digital rectal examination (DRE) to assess its size, shape, and consistency. A DRE is among the steps necessary to diagnose benign prostatic hyperplasia, or BPH. In tandem with prostate specific antigen (PSA) testing, the DRE exam is also an essential screening tool for prostate cancer.

The American Cancer Society and American Urology Association recommend that all men over age 50 have a DRE (along with a PSA test) once a year—and earlier if they are at high risk for prostate cancer.

Despite this recommendation, a study published in the Archives of Internal Medicine found that only 47% of 588 men who underwent PSA testing also had a DRE performed. Skipping a DRE means that many men with prostate cancer and a normal PSA result will go undiagnosed.

Some men avoid getting a DRE because they feel uncomfortable about the procedure—but it is not painful and lasts less than a minute. During a DRE, the patient either bends forward over the examination table, lies on his side, or kneels on the table. The doctor then inserts a gloved, lubricated finger a few inches into the rectum and gently palpates the prostate gland to feel for a nodule or lump, change in size, hard tissue, or any other abnormality that might indicate a tumor is present.

Johns Hopkins Health Alerts | Prostate Disorders | DRE Test for Prostate Cancer

Before You Give Up On Viagra

Mon, 17 Apr 2006 13:43:34 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Correct Viagra Usage

Researchers have discovered that many of these so-called “Viagra failures” were actually using the drug improperly.

Men who undergo radical prostatectomy or radiation therapy for prostate cancer often fear they will be unable to resume sexual activity after treatment. If a procedure does result in erectile dysfunction, oral medications—the newest advance in the treatment of erectile dysfunction—are often the initial therapy.

Of these drugs, Viagra (sildenafil) is the oldest and still the best known, (Other popular drugs include Levitra and Cialis.) Yet while Viagra has helped many men, others who tried it found that it didn’t work.

However, researchers have discovered that many of these so-called “Viagra failures” were actually using the drug improperly. Some of the men had taken Viagra after a heavy meal, which may interfere with absorption of the medication. Others took a suboptimal dose of Viagra (50 mg instead of 100 mg, the highest dose), or they expected results too soon after taking Viagra.

Other men completely overlooked the role of direct sexual stimulation (having the partner becoming more involved in the sexual process is critically important) in achieving an erection suitable for partner penetration.

Then, too, some men gave up on the drug after trying Viagra just once.

Mistakes such as these may explain why a significant number of men don’t renew their Viagra prescriptions—and also indicate why it’s important that you discuss with your doctor any problems you are having with Viagra or a similar erectile dysfunction medication rather than simply assuming it doesn’t work for you.

Johns Hopkins Health Alerts | Prostate Disorders | Correct Viagra Usage

Treating Benign Prostatic Hyperplasia (BPH)-- One Option Is To Wait

Thu, 13 Apr 2006 21:33:52 CDT

Johns Hopkins Health Alerts | Prostate Disorders | Treating Benign Prostatic Hyperplasia (BPH)

During expectant management, you should adopt certain lifestyle measures to help relieve symptoms of mild Benign Prostatic Hyperplasia (BPH) and prevent them from worsening.

Doctors can’t predict how quickly an enlarged prostate will require treatment. Symptoms and objective measurements of obstruction in the urethra associated with benign prostatic hyperplasia (BPH) can remain stable for many years and may even improve over time in as many as a third of men. In one study from the Mayo Clinic, urinary symptoms did not worsen over a 3 1/2-year period in 73% of men with mild BPH.

Because the progression of and complications from BPH are unpredictable, expectant management —meaning that you are closely monitored but no immediate treatment is attempted—is best for men with minimal BPH symptoms that are not especially bothersome. With this treatment option for BPH, you only need to see your doctor about once a year to review the progress of symptoms and undergo a physical examination a few simple laboratory tests.

During expectant management, you should adopt certain lifestyle measures to help relieve symptoms of BPH and prevent them from worsening. For example, you should not take over-the-counter antihistamines and decongestants and should avoid delaying urination. If you have BPH you also need to be careful about your fluid intake by avoiding beverages that contain caffeine, limiting alcohol intake and the amount of fluid consumed at any one time, and avoiding beverages after 7 p.m.

Other helpful measures for these men with BPH include limiting spicy or salty foods, keeping warm, engaging in regular physical activity, and doing Kegel exercises (which involve squeezing and relaxing the pelvic floor muscles that support the bladder and surround the urethra).

Johns Hopkins Health Alerts | Prostate Disorders | Treating Benign Prostatic Hyperplasia (BPH)