Doctor's Q & A

If you have a question you would like to address to the panel, please send it via email to:

doctorshelp@jupiterprostategroup.org It will be forwarded to the Medical Advisory Board and also will be posted on this page for others to respond to.

Dr. Robert Green has left our MAB because of time constraints. We thank him for his service.

BIOS: The following physicians have graciously volunteered to serve on the MAB:

Dr. David Ahr - Dr. Ahr is currently a Physician Partner with the Palm Beach Cancer Institute. He received his MD from Georgetown University and did his internship and residency at the US Army Medical Center in Honolulu, Hawaii. Following that he had a fellowship at the Walter Reed Army Medical Center in Washington, DC. After serving as the Director of the Coagulation Laboratory he then came to West Palm Beach and currently practices in Hematology/Oncology at the PBCI. Dr. Ahr deals with the full spectrum of cancers with a large prostate cancer practice.

Dr. Frank Ervolino, ND - Dr. Ervolino received his ND from Bastyr University in Seattle in 1995. He also received an MS in Acupuncture in 1999 from Bastyr. Dr. Ervolina has been in private practise in this area since 1996. He is a free-lance writer on health topics for several publications and is a columnist for Better Nutrition Magazine where, in 2004 he was appointed Senior Research Editor. He also is on the JMC Medical Staff and has been a principal in the Mind Body Institute at the JMC.

Dr. William H. Gans - Dr. Gans is currently a Staff Urologist with Urologic Specialties of Lake Worth, FL. He has privileges in all of our local hospitals: Jupiter Medical Center, JFK Medical Center, Palm Beach Gardens Med Ctr, Palms West Hospital, and Wellington Regional Med. Ctr.

Dr. Gans received his undergraduate education at Binghamton University with a BS in Biology in 1993. He received his MD degree at the Upstate Medical University in Syracuse, NY in 1997. During his career he has received much recognition including the Pfizer "Scholar in Urology" award in 2002. He received training in General Surgery at Mount Sinai Hospital in NY and did his Urology residence there as well.

Dr. David M. Herold - Dr. Herold is currently Medical Director of the Radiation Oncology Dept. at the Ella Milbank Foshay Cancer Center. He was educated at Thomas Jefferson University Hospital in Philadelphia and has received advanced training in radiology at Fox Chase Cancer Center in Philadelphia as well as at MD Anderson Cancer Center in Houston, Texas. Dr. Herold is well schooled in the use of IMRT, High Dose Rate Brachytherapy, Electron Beam Radiotherapy, Radiopharmaceuticals and the newest Cyberknife robot. He currently oversees and practices in prostate, breast, lung, lymphomas, CNS, colorectal and skin cancer.

Dr. S. J. Hulecki - Received his AB degree in biology from Indiana University in 1973 and his MD from the University of Rome, Rome Itlay in 1978. He served his surgery residency at the Medical College of Virginia where he was Chief Resident and a fellow with the National Bladder Cancer Study Group A. He has presented many lectures on a wide variety of urological topics and currently is with Advanced Urology Associates of Florida, in Vero Beach. Dr. Hulecki is an authority on the use of Cryosurgery for so-called "Male Lumpectomies" and uses the most recent generation of Endocare Cryosurgery equipment in his practise.

Dr. Evan Rosen - He graduated Emory University in 1986 and received his MD from Georgetown U. in 1990. His surgical residency was done in urology at the Beth Israel Medical Center in NY. He served as Chief of Surgery at the JMC from 2001-2004 and is currently on their Medical Executive Committee. Currently serves as Vice Chief of Staff at JMC. He is in private practice in Jupiter as a Urologist.

Dr. Jerome J. Spunberg - Dr. Spunberg is a Board certified radiation oncologist. He is a graduate (summa cum laude) of Columbia University in 1973 and received his MD from Harvard University in 1977. His residency was done at Columbia Presbyterian Hospital where he served as Chief Resident and Clinical Fellow. He is a member of several professional radiation societies and is the Medical Advisor to PB County's ACS unit. Currently, he practices at the Radiation Oncology Institute in PB Gardens and at JFK Medical Center's Cancer Center.

Dr. Bruce Wiita - Dr. Wiita is a urologist who has been practicing in So. Florida since 1972. His undergraduate work was done at the U. of Miami where he earned his MD. His post-graduate training included a residency at Travis AFB in California. He was a general surgery resident at Jackson Memorial in Miami and also did his urology residency there. He served as an Air Force Flight Surgeon in Viet Nam from 1965 - 1968. Dr. Wiita has served as the Chief of Surgery at the Jupiter Medical Center. He is a board certified urologist and is a member of several professional societies.

"I read a lot about new vaccine therapy for prostate cancer. What vaccine or vaccines are actually available that can be used for men experiencing rising PSA after radiotherapy? Are there any clinical trials in our vicinity?" Thank you, Mr. J.D.

Vaccines for prostate cancer have been under development for 10+ years. Unfortunately, these are limited to Stage I and Stage 2 trials with several problems including reports of death from the vaccine carrier. The future looks bright for a vaccine, but clinical trials involve taking each man's specific cancer and attaching it to a virus and then vaccinating them against their own cancer cells. There is no program available for men with rising PSA and vaccine therapy.

There is a program for Dendritic cell therapy that costs about $50K. For men with rising PSA after radiation therapy, there are 3 therapies available:

1. Hormone therapy, 2. Watchful waiting, and 3. Cryotherapy as salvage therapy for men with disease confined to the prostate.

The only vaccine I know about is Provenge(r) made by Dendreon. I think it is approved now for metastatic asymptomatic prostate cancer.

[Ed. Note: Dendreon Corp. has been working on its Provenge(r) vaccine for several years. It has gone through Phase III trials and it has an application for approval pending before the FDA. The application is being reviewed by the FDA's CTGT (Cellular Therapy and Gene Therapy) Advisory Panel. Some kind of action is expected before the end of March, 2007. There is a huge short position in the stock that seems unusual because the data, at least for men who had Gleason tumors of <= 7.0, showed positive results. There were no "cures" but there were increases reported in overall survival. For those who want more info we suggest going directly to Dendreon's web site <www.dendreon.com> where all the trial results and upcoming trials can be found. A new trial is recruiting patients now: Hematology/Oncology Associates, Port St. Lucie, FL 772-408-5159. Additional vaccine information will be added to this site later.]

"I recently read an article that stated Botox can shrink prostates. How often must a patient receive shots? Is this procedure covered by insurance? Is this report factual?"

In August, 2003 WebMD Medical News published a story that discussed this procedure as it was reported by Dr. G. Maria of University Hospital Agostino Gemelli in Rome. He reported on treating 30 men with "severe" BPH. Half got Botox and the other half got injections of saline solution. The men started with a score of 23 on the 35 point AUA BPH Symptom Index. This is considered quite high. After two months, the Botox group had a symptom score of 8. A score of 0-7 is rated "mild".

In addition to the reduction in Symptoms Index, he reported that the glands themselves shrank to half their starting size and PSA levels "also dropped". No data was given in the write-up.

BOTOX in the USA is only approved for cosmetic purposes currently. Dr. Gemelli warned that "Botox is still a neurotoxin with potential and significant life-threatening morbidities".

"I had laparoscopic surgery for prostate cancer three years ago. Currently I require at least two pads per day for my incontinence. Are there any new medicines available to help me deal with this? Is there a surgical approach to resolving my problem and, if so, how successful is it?"

There are many new meds available that you should discuss with your physician. Further evaluation needs to be done before talking about additional surgery.

"I have had XBRT three years ago for prostate cancer. Have some chronic incontinence problems since then. Are Kegel exercises useful after this long time period? How long after primary therapy are Kegels likely to help?"

If Kegel exercises haven't helped yet, they probably wont. If they have helped over time, then continuing with them will help the incontinence issues. The most important and effective time to do them is following the initial surgery.

Kegel exercises are helpful for stress incontinence. If the patient is experiencing urge incontinence after radiation therapy, Kegels aren't likely to be effective.

"Many men continue to experience treatment failures after primary therapy. What is (or are) the most useful method (s) to determine whether the cancer is already outside of the gland before a treatment is chosen? Are there any new methods coming into use to achieve this objective? And, is the reason for so much post treatment failure because we can't detect cancer outside the prostate in the early stages of the disease?"

The current range of diagnostic procedures, e.g. DRE, PSA, GLEASON SCORE, and sometimes radiographic imaging taken together help to determine if the cancer is out of the gland prior to treatment. [Ed. Note: The Partin Tables and other nomograms have been developed to estimate probabilities of extra-capsular extension, seminal vesicle involvement, lymph node involvement, etc. They can help estimate the likelihood of ECE given all the disease parameters.]

What other disease parameters beside PSA are the most important when considering radiation treatment?

The regular prostate cancer diagnostic parameters should be obtained: Gleason, number of positive cores, estimate of amount of Gleason pattern 4 or higher, proximity of cancer to gland margins, etc. As in all prostate treatment modalities, the relative risk of extra capsular extension prior to therapy is still difficult to calculate. Radiation dosage has to be carefully maximized to destroy tumor cells without damaging peripheral tissue and/or organs.

This condition normally implies that not all the cancer cells were killed by the radiation therapy. Or, it may also mean that there was cancer already beyond the gland at the time of treatment.

Are there specific PSA levels or ranges of levels that are significant in post radiation therapy?

Probably the most important aspect here is the rate of change of the PSA. The shorter the doubling time, for example, the more worrisome the condition. Treatment with hormonal blockade therapy is normally started during the post radiation rise in PSA. Doctors vary in how soon they begin treating the patient with the HRB therapy.

With the increasing amounts of "anti-screening" literature that are appearing, should men begin to back off PSA testing? Can the Doctors clarify this issue, please!

[Ed. Note: None of the Medical Advisory Board have yet replied to this question. The following thoughts are the Editor's personal opinion]

The arguments being presented by the anti-screening articles are mostly concerned with what they call "over treatment" for cancers that might never become life threatening. Of course this begs the question of how we can one know which cancers are or aren't, life threatening. Given typical biopsy results one cannot, with any real certainty, separate the potential "killers" from the pussy cats. So it comes down to the individual's attitude: does a man benefit by knowing he has prostate cancer, even in its earliest stage, or is it better to ignore it until symptoms appear?

We are told, and statistics bear this out, that early detection means higher cure rates! If a man knows he has an early stage prostate cancer then he has a choice: watch it carefully or attack it aggressively. Because of potential treatment side effects this is a major decision that should be discussed in depth with the patient's physician. A man can live or die as a result of this decision.

PSA was a major breakthrough in diagnostic power. Used properly by men at risk screening can be life saving. Therefore it is the Editor's opinion that men over 60 should continue being screened by PSA and DRE

Is cryosurgery as effective as radiation in providing long term relief from PCa? How do its side effects compare to those of radiation therapy?

Dr. Spunberg answers this question: "I am not convinced that cryosurgery is a proven and effective treatment for prostate cancer. There have been numerous complications from cryo in the earlier experience and not enough time has passed to fully evaluate this approach. I generally do not recommend it in light of other proven approaches."

Dr. Stephen Hulecki, practicing urologic cryosurgeon, has replied to this question as follows:

"Cryo of the prostate for prostate cancer has been actively done since the very early 1990's It's 10 year track record has been well recorded in the literature and presented at all of the major Urological and Medical oncological forums. It is an approve therapy for T1-T3 prostate cancers and is the only medicare approved therapy for radiation therapy failures. For low risk disease all treatment options have a similar outcome at 10 years. For medium risk disease, Cryo outperforms all other therapies. For high risk disease, Cryo is the clear leader in provididng the statistical advantage. There are several caveats. Only 500 urologists currently have an active cryo program (more than 25 cases per year). The best results are achieved by those Cryosurgeons that are routinely using this form of therapy. With regards to the complication rates, the use of the Argon based cryo machines has virtually eliminated the rectal fistulas that were occurring at a rate of 2-5% in the mid 1990's. The patient may have the option of "nerve sparing cryo" and an exciting option is being offered by several cryosurgeons - the "male lumpectomy". I would refer anyone the the web sites at Oncura and Endocare."

[Ed Note: We will have a writeup on the site that discusses the concept of the "Male Lumpectormy" as developed and practised by Dr. Gary Onik of Celebration, FL. He presented a comprehensive lecture on the subject at the International Prostate Cancer Forum in Reston, VA Oct. 19 -22, 2006]

I've been reading about microwave therapy for treating tumors. They say that heating a tumor will kill it. How does this work and is it being used to kill prostate tumors? Is it the same thing that's being used in BPH to relieve constrictions?

Dr. W. Gans answers:" Microwave thermotherapy is experimental at this point in this country so I cannot comment until I see the data. Based upon short term data from Europe, it does appear to be effective.

TUMT, Trans-Urethral Microwave Therapy, is in limited use around the country. As opposed to mechanical tissue ablation as done in a TURP, a TUMT ablates excess tissue using heat created locally by microwaves. So the tissue is removed and cauterized at the same time greatly reducing bleeding.

Heating tumors to effect cell kill falls under the general heading of HYPERTHERMIA. This has been used for many solid tumors in Europe for some years and has only recently been approved by the FDA for use in the USA. A company called BMD is offering Hyperthermia systems for this purpose. For further info, check out the BMD web site.

Another system using heat to ablate prostate tissue is called HIFU: acronym for High Intensity Focused Ultrasound. This technique generates high temperatures by focusing ultrasound to a small diameter locus and "burns" away tissue. Think of when you were a kid trying to fry bugs with a magnifying glass on a sunny day. It hasn't been approved in the USA yet. One of our J-TUT members did undergo the procedure in the Dominican Republic and will share his experiences with anyone interested. Contact Editor.

Are there any new drug approaches being used to reduce testosterone to castrate levels for men who are dealing with a rising PSA after a primary treatment?

Dr. Gans replies: "There is no new therapy for lowering testosterone. Treatment with LHRH agonists (Lupron, Zoladex, Elagard, etc.) or physical orchiectomy are effective".

What is the longest period men have gone without rising PSA during intermittent hormonal treatment? How many cycles can one expect before the approach stops working?

Dr. Gans replies: "Intermittent therapy is promising, but there is not much data about when to restart the therapy and whether there is a difference in the time until development of androgen independent disease. The main reason to use intermittent therapy in my opinion is if the patient has intolerable side effects from LHRH therapy".

[Ed. Note: The literature has many papers that discuss this issue. The effectiveness of the approach seems to be directly related to the initial aggressiveness of the tumor. Those men with Gleason's 6 or lower and small initial tumor burdens, respond with longer "off drug" periods and shorter "on drug" periods. A new paper just published reports that post-primary therapy PSA doubling rate is a strong indicator of likely success or failure with IHB. We will discuss this paper in more detail later.]

Dr. David Ahr has replied to the above two questions about hormonal blockade therapy as follows:

"No one knows how best to use androgen ablation after PSA-only failure following primary therapy. There are several approaches to intermittent androgen blockade being investigated. All are driven by a desire to reduce the long term side effects associated with reduced circulating testosterone levels.

An interesting approach with long term results was recently presented at ASCO (Abstract 4513). Patients were given 3 months of androgen blockade therapy after PSA-only failure [Ed Note: as evidenced by a rising PSA]. 626 patients who dropped PSA to <4.0 were randomized to intermittent or continuous therapy. Treatment was resumed in the intermittent group when the PSA increased to >10 with symptoms or >20 without symptoms and again stopped if PSA fell to prior levels. Among the intermittent group, 50% remained off therapy for 52 weeks following induction therapy, and 29% have not required additional therapy for more than 36 months. For patients whose PSA fell to <2 after induction, the median time without therapy after induction was 74 weeks. In the overall population, patients whose PSA fell to <2 spent 82% of their time without treatment. Clearly they had hormone responsive disease and did well. In contrast, patients with PSA levels of >4 at random assignment (after three months of hormone induction ablation) were without therapy for a median of only 16 weeks. The number of deaths was virtually identical in both groups. Survival was poorer for pts in the continuous-therapy arm (they did not achieve PSA <4 after three months of induction therapy) and in pts with metastatic disease at the time of randomization.

The bottom line again seems to be that it's good to have hormone responsive disease, and if you do, you may not need to be on androgen blockade all the time, incurring the risk of side effects seen with continuous androgen blockade. Stay tuned as many other studies are in progress.

[Ed. Note: A recent article by Semeniuk, et. al. in Urology, Sep(68) 06, 565-569 discussed the significance of PSA doubling time (PSADT) in men who had shown rising PSAs after primary therapy. They reported that in their sample of men taken from charts between 1998 and 2002 (number was not disclosed in the abstract) those who had PSADT of < = 70 days survived (median) for 11 months compared to 19 months median survival for those with PSADT of >70 days. Overall, the median survival from the time of HRPC diagnosis was reported to be 15.1 months. However, the 95% confidence range for this median was 0.5 to 90.5 months. Put simply, they found that individual survival after the HRPC dx went from a couple of weeks to over 7 YEARS! The most one can conclude from such a study is that a faster doubling time following PSA failure is more predictive of a shorter life-span than is a longer PSADT. The stratification point was 70 days PSADT.

Although the numbers are different, the principle showing the predictive utility of PSADT before primary therapy is the same as after PSA rise following hormonal blockade therapy. If a man shows a rapid PSA doubling time, it tells him and his Dr. that they are dealing with an aggressive kind of tumor.]

Have any of the MAB had experience with the use of estrogen patches in a patient who has failed RRP and has had five rounds of IHT. He seems to be hormone refractory at this time. How effective was the use of the estrogen patch? How long did the effect persist? Were there side effects different from Lupron, etc.? Thank You, Mrs. C. B.

1. Data in the literature shows that five year survival rates for all of the current treatment methods (surgery, radiation, cryosurgery, etc.) are all about the same, i.e., close to 100%. What factors should a man consider when he is trying to choose among them?

Dr. Spunberg replies: There are many factors to consider in selecting a treatment approach. First of all "to treat or not to treat?" That depends on age, PSA, Gleason Score, personal preferences, and more. Surgery is usually reserved for the "under 65" age group but occasionally older patients opt for it and younger patients choose otherwise. The need for preservation of sexual performance is also an important consideration, as surgery often results in impotence whereas seed implants offer perhaps the best chance for maintaining normal erections and performance. Five year survival rates are too short for comparison with PCa. You need to look at 10-15 year data for meaningful comparisons.

2. My radiation treatments (seeds plus beam radiation) of three years ago seemed to have cured my prostate cancer. Now my PSA is beginning to rise again. Why is this happening? What can I do to stop this rise? Is Lupron treatment the standard for my condition?

Dr. Spunberg replies: The PSA may be rising due to local, regional, or distant recurrence. It is often difficult or impossible to determine the cause of the rise, and hormonal therapy is usually the treatment approach. Lupron will almost always cause the PSA to drop to close to zero but this may prove to be only a temporary measure, as later on the PSA will often start to rise again.

The treatments that you had 3 years ago did NOT cure your porstate cancer. If you have had 3 successive rises in your psa over the past year, ASCO suggests that you have failed the therapy AND need a repeat evaluation with repeat US and Biopsy.

If the Bx is positive, then a metastatic work up is recommended with a minimal evaluation using an EndoRectal MRI. Most Urologists and Oncologists will ask for a Bone Scan and Pelvic CT or a Fusion test of CT and Prostascint to reevaluste the Stage of the disease.

If the disease is localized then you are an excellent candidate for Cryotherapy salvage and the 7 yr. disease free rates are 78-84%.

Lupron is also an option, but recommendations are for it's use in metastatic disease states, and then with Total Androgen Blockade (DrBob.com).

3. Is there any test for determining if my PCa is already outside the capsule when I got my diagnosis? Can I have an MRI or CAT scan to determine this? Is there any chemical test that might tell me?

Dr. Spunberg replies: Extra-capsular extension correlates with Gleason Score, PSA, and extent of involvement of the prostate. MRI may show this extension best, but is not entirely reliable. Only after surgery when the pathologic material is examined can a definite answer be obtained with certainty.

The Endorectal MRI is the exam of choice for the best "visualization" of the prostatic capsule, seminal vesicles and pelvic lymph nodes. I am a big proponent of this exam and it offers more info than a Bone Scan and Pelvic CT, since it is reliable to 3 mm and most CT are only able to "see" down to 5-6 mm. Dr. D'Amico from Harvard has published extensively and the Urology community, now recognizes it's importance in restaging for men with PCa recurrence. Currently, there are no chemical tests. A Prostascint exam may be helpful, especially fused with a E-coil. Jupiter Hospital has a good Endorectal MRI program that I have used over the past 5 years.

4. My PSA is slowly rising (from 3.1 to 4.2 in seven months). I'm 67 years old and my DRE was negative. My doctor has ordered only a PSA test. Should I get a % Free PSA as well? Will this tell me more about my situation?

Dr. Hulecki Replies: If your PSA is rising it is recommended that you consider a 3 week course of Antibiotics and saw palmetto, then at 6 weeks have a free and total PSA to determine your risk stratification for Prostate Cancer. If the free PSA is > 25 % then you have a very low risk for prostate cancer even if your PSA is slighly elevated.

5. I had prostate surgery sixteen months ago and now my PSA is creeping up slowly. At what point should I think about starting hormonal treatments? PSA is currently less than 1.0. When should I consider going on hormonal therapy? How effective can I expect the hormonal therapy to be? Is there any "salvage" procedure for somebody who doesn't' t have a prostate anymore?

[Dr. Spunberg replies: The way to handle this problem is somewhat controversial. Some physicians start hormonal therapy early on, and others wait until the PSA reaches some arbitrary level. Once hormonal therapy is utilized, the PSA will usually drop to very low levels, sometimes for years. Radiation therapy as either IMRT or IGRT can be used for an isolated local recurrence, even for cure.

[Ed. Note: This is the kind of situation extensively reported on in the prostate literature. It happens when any of the primary treatment methods fail to totally eradicate the PCa. How the situation appears to be approached is quite empirical. Some oncologists favor immediate response with LHRH agonists (Lupron, etc.) while others recommend allowing the PSA to increase to some arbitrary level before beginning LHRH treatment. Because of the multiple side effects possible from LHRH agonist usage, there seems to be a preference for allowing the PSA to exceed 3.0 or 4.0 before beginning the drug treatment. One should carefully review the published approaches to this condition, discuss it with his oncologist (or urologist) and also consider intermittent hormonal blockade therapy.]

6. In Dr. Strum's book, "A Primer on Prostate Cancer" he recommends that men have PAP tests as well as PSA. I know that PAP is an older test so I wonder what useful information it would provide beyond the PSA test?

Dr. Spunberg replies: I don't know why the PAP would still be recommended. Very few patients seem to have one these days, and PSA is far more sensitive. [Ed. Note: The PAP, according to some reports in the literature, can serve as a prognostic indicator for the future course of the disease]

[Ed. Note: In Dr. Steven Strum's book, "A Primer on Prostate Cancer", p. 52-53, you can find a discussion about the usefulness of PAP data in predicting post radiation failure probability. He cites data from Moul and Dattoli that shows the significance of PAP levels > or = to 3.0. Higher PAP values were correlated with greater risk of tx failure.]

1. Has anyone had any experience with using ketoconazole and hydrocortisone in hormone refractory patients?

Ketoconazole and hydrocortisone is not appropriate for hormone refractory patients. By definition, these patients have castrate levels of testosterone on lhrh agonists or via physical orchiectomy (i.e. castration). These are effective if a patient does not have a castrate level of testosterone or if immediate castration is needed.

Ketoconazole is a medication that has been around for 20+ years. We have found that it has antitestosterone properties. It can lower the testosterone level and subsequently the PSA in hormone refractory prostate cancer. It is used as a "salvage" therapy in men who are failing triple hormone blockade ( LHRH + anti-androgens + Proscar). Prednisone is used in conjunction since the adrenal glands may also need support.

The original uses of Ketoconazoel(Nizoral) has been used for severe fungal infections. For prostate cancer, it is considered third line therapy after trying Anti-androgen withdrawal. It is important to watch the liver function tests in it's usage. There is an immediate testosterone lowering within 24 hours and subsequently a lowering of the PSA in about 40% of patients within 2-3 weeks.

Dr. Rothschild replies:

This is the first question i think i can reply to in less than 30 minutes.... keto is an occasionally effective 2nd or 3rd line hormonal therapy that for most patients is well tolerated -- i have had a number of very gratifying responses but occasionally patients can have severe side effects including nausea, fatigue, rash and liver function abnormalities. fortunately these are uncommon but should be watched for.