Re: Question on doubling time

[Guest guest]

Lynn,

People tend to overlook the fact that PSA

is NOT prostate cancer specific when discussing PSA levels. So a variance in

PSA numbers does NOT automatically mean that it is generated by prostate cancer.

There are many studies showing that in at least two thirds of cases where there

is a biopsy after an elevated PSA result there is no diagnosis of prostate

cancer. On the other hand another major study showed that if men with a PSA

less than 4.00 ng/ml (the level that is regarded as ‘normal’) there

would be as many, or more, men found with prostate cancer. That is one of

the reasons why PSA is not a good tool for diagnosis.

The main cause of elevated PSA is BPH

(Benign Prostatic Hyperplasia) or an infection in the bladder or prostate,

rather than prostate cancer, although of course prostate cancer can also cause

excess amounts of PSA to be found. These infections are difficult to diagnose

at times and also difficult to treat. One urologist described a warm pool of

urine in the bladder as being like a holiday resort for bacteria. Typically

elevated PSA levels associated with infections will tend to vary up and down

where PSA associated with prostate cancer will tend to increase at an ever

increasing rate – and this is where the doubling time comes in, Of course

just to confuse the issue a little more, in cases where there is severe BPH

(Benign Prostatic Hyperplasia) the PSA levels will also tend to increase as the

size of the gland increases.

When a man is ‘intact’, which

is to say he has his prostate gland and it has not been treated in any way,

there are multiple potential causes of variation in PSA levels: prostate cancer

is one of them, but not the only one. I don’t know if you have looked at the

experiment I did ten years or so ago – it is at http://www.yananow.org/PSAexperiment.htm

Although it clearly does not meet any scientific basis, it does illustrate what

can happen to PSA levels over a period of 28 days where the same laboratory is

used and where every effort is made to stabilize the PSA values.

There are surprisingly few studies that

show mortality rates for the various treatment options. Most studies are fairly

short term and, since very few men die of prostate cancer compared with other

causes and even fewer die within a short time of diagnosis, the mortality rates

in these studies are low. I have not seen a large study correlating prostate

cancer deaths with PSA doubling times.

The largest study looking at the issue of

dying without treatment that I know of was done in the pre-PSA era. It was published

in 1998 and is titled Competing risk analysis of men

aged 55 to 74 years at diagnosis managed conservatively for clinically

localized prostate cancer. Albertsen PC, Hanley JA, Gleason DF, Barry MJ.JAMA

1998 Sep 16;280(11):975-80. A full copy of the study is available if you go to

Jama and sign up at no cost. This is the summary of the results

·

Men with tumors that have Gleason scores of 2 to 4 face a 4% to 7%

chance of dying from prostate cancer within 15 years of diagnosis depending on

their age at diagnosis.

·

Men with tumors that have a Gleason score of 5 face a 6% to 11% chance

of dying from prostate cancer within 15 years of diagnosis depending on their

age at diagnosis

·

Men with tumors that have a Gleason score of 6 face a 18% to 30% chance

of dying from prostate cancer within 15 years of diagnosis depending on their

age at diagnosis

·

Men with tumors that have a Gleason scores of 7 face a 42% to 70% chance

of dying from prostate cancer within 15 years of diagnosis depending on their

age at diagnosis and

·

Men with tumors that have Gleason scores of 8 to 10 face a 60% to

87% chance of dying from prostate cancer within 15 years of diagnosis depending

on their age at diagnosis.

BUT……there

are a number of issues that have to be understood when looking at data like

this, collected before the PSA test was used in diagnosis. Where the majority

of men are now diagnosed with early stage and lower risk disease, back then men

were generally only diagnosed with advanced disease – because they

had developed symptoms of the disease – or because they had urinary

constrictions, whether from BPH (Benign Prostate Hyperplasia) or prostate

cancer and the disease was discovered after a TURP (Trans Urethral Resection of

the Prostate).

The other, major factor

that affects an interpretation of the results is that the method of grading

tumour samples and the resultant Gleason Score have changed significantly since

this study was written. There has been a so-called ‘migration’

of Gleason Scores so that what was once a GS 5 or 6 may now be a GS 7: a GS 7

back then may now be a GS 8 and so on (You can read a good article on this here

http://tinyurl.com/2jnpbu ). And of

course, Gleason Scores lower than 3+3=6 in samples obtained by needle biopsy are

no longer treated as prostate cancer – see http://www.yananow.org/StrangePlace/forest.html#gleason

I faced your kind of

problem when trying to assess my own mortality risk since I had four opinions

from pathologists scoring my biopsy samples as GS5, GS 6 and GS 7 – and that

was before migration altered the values. Which to take? Overall the opinions

gave me a spread from best a 6% chance of dying in 15 years to a worst case of 70%

chance of dying in fifteen years. I took the former and, so far, it looks as if

I’ll make the fifteen year cut-off in August this year.

I am not saying my

decision was the ‘right’ one, because there are no ‘right’

decisions in dealing with this disease. There is a multiplicity of decisions

and we must all make the one that suits us best, balancing the best guess

probabilities of the disease progressing against the damage to quality of life

that is inevitably associated with treatments. If anyone is interested in how

and why I chose not to have treatment, the story is here http://www.yananow.org/whynotsurgery.htm

I’d like to

conclude by referring to Chuck’s mail where he says

<snip> I’m

not directing this at you, but rather at your husband – what does he

expect is going to happen with his doing absolutely nothing with what could be

a deadly form of prostate cancer? Does he truly think it will just

subside and disappear? Absolutely not, and if anything it could become

excessively aggressive and become beyond many/most medications to rein in. <snip>

I doubt that anyone with

a prostate cancer diagnosis thinks it will just subside and disappear. I think

that most people accept that the disease can become more aggressive and

life-threatening. But each of us has all manner of risks to contemplate in our

lives – I was personally almost cured of my prostate cancer by a heart

failure episode only five years ago and, whichever way you slice it, prostate

cancer is certainly not a leading cause of death in men. On the latest figures

it ranks about #7 at about one third of the deaths from accidents and

accounting for less than 3% of male deaths about the same as it was in 1976.

All the best

Terry Herbert

in Melbourne

Australia

Diagnosed ‘96: Age

54: Stage T2b: PSA 7.2: Gleason 7: No treatment. Jun '07 PSA 42.0 - Bony

Metastasis: Aug '07: Intermittent ADT: PSA 2.3 Feb ‘11

My site is at www.prostatecancerwatchfulwaiting.co.za

It is a

tragedy of the world that no one knows what he doesn’t know, and the less

a man knows, the more sure he is that he knows everything. Joyce

Carey

From: ProstateCancerSupport [mailto:ProstateCancerSupport ] On Behalf Of LYNN

Sent: Monday, 30 May 2011 3:16 AM

To: ProstateCancerSupport

Subject:

Question on doubling time

My

husband was diagnosed in January 2010 with a PSA of 7.4 and GS of 4+3. He is

not really happy with any of his alternatives, so we have just been watching

his PSA. In the last 18 months it went down to 6.5 and this month was at 9.96.

My question is this: are there any

statistics on doubling time of PSA when no treatment has been done? I could

find statistics on doubling time of PSA and their relative outcomes for men who

had their prostates removed, but nothing about men who were not treated.

Do any you know where to look or what the mortality rate associated with

doubling time is for non-treatment?

Thank you so much.

Lynn

[Guest guest]

Prostate Cancer SupportHello Lynn,

The short answer to you question is yes, there is considerable information

on the PSA doubling time prior to any treatment.

This comes out of the growing number of institutions following appropriately

selected men defering immediate treatment for Active Surveillance.

The most common approach is to suggest that a PSA doubling time of three

years or less indicates that the cancer has become aggressive and needs

treatment.

However, nothing about our disease is simple.

The most common criteria for deferring treatment include:

PSA no more than 10.

PSA density (PSA divided by prostate size from the biopsy ultrasound) less

than 0.1 to 0.15

No more than three cores in the biopsy positive for cancer.

No more than 30 to 50% of any single core positive.

No Gleason 4 pattern as the primary number.

You and your husband should derive as much information as possible from the

biopsy report in order to estimate his cancer stage and decided on a course

of action.

o How many cores were taken? Modern biopsies should take at least 12

cores.

o How many cores were positive for cancer?

o How much cancer was there in each positive core?

o What was the prostate size? The larger the prostate, the more PSA can be

generated by benign tissue, not cancer.

The biopsy indication of Gleason pattern 4 as the primary number in the 4+3

may indicate a more serious cancer not appropriate for long-term avoidance

of treatment. The Gleason information is so important that you should

consider having the biopsy slides sent to an expert lab for a second opinion

on the pathology. This is covered by most insurance. The lab that did his

biopsy pathology can arrange this. Among the recommended labs specializing

in prostate pathology are Bostwick and Epstein (s Hopkins). Bostick can

also do DNA ploidy analysis to provide additional information on the cancer

aggressivenes.

https://www.bostwicklaboratories.com/global/services/laboratory-services/second-\

opinions.aspx

http://www.hopkinsmedicine.org/second_opinion/urology/index.html

PSA is an important, but not definitive, biomarker for prostate cancer. To

accurately estimate the doubling time one should have a series of PSA

readings ideally spanning at least two years. The more the better. The

number you provided suggest an erratic PSA history that could be due to

prostate infection or inflammation as well as cancer. If you have more PSA

values over time, one can calculate the doubling time. There are several

web sites that will calculate PSA doubling times; the second one below also

includes programs where you can include the PSA record and biopsy

information to estimate the probability of cancer control with treatments.

http://www.doubling-time.com/compute-PSA-doubling-time.php

http://nomograms.mskcc.org/index.aspx

I also have an Excel spreadsheet I could send you that plots PSAs over time

and calculates the doubling time.

However, given what you have provided, in your husband's shoes I would first

get a second opinion on the biopsy pathology and look at all the information

that can be gleaned from the biopsy. If there is significant (more than

30%) Gleason 4+3 in multiple cores, I would be giving serious consideration

to treatment. Today there are a number of valid treatment options other

than radical surgery.

If the second opinion suggests that Active Surveillance may be an option,

there is an abundance of information on those procedues, including color

Doppler Ultrasound or MRI imaging to get more information on how much cancer

may be present. If you decide to follow that route, I can provide a number

of references. I've been doing Active Surveillance for five years and stay

current on the medical literature.

The Best to You and Yours!

Jon in Nevada

==========================

Question on doubling time

Posted by: " LYNN " adopt4u@... luvmyrhett

Sun May 29, 2011 10:16 am (PDT)

My husband was diagnosed in January 2010 with a PSA of 7.4 and GS of 4+3. He

is not really happy with any of his alternatives, so we have just been

watching his PSA. In the last 18 months it went down to 6.5 and this month

was at 9.96.

My question is this: are there any statistics on doubling time of PSA when

no treatment has been done? I could find statistics on doubling time of PSA

and their relative outcomes for men who had their prostates removed, but

nothing about men who were not treated.

Do any you know where to look or what the mortality rate associated with

doubling time is for non-treatment?

Thank you so much.

Lynn

[Guest guest]

Jon.

Where are the best places to go for Color Doppler and MRI?

Thanks.

Doug

>

> Prostate Cancer SupportHello Lynn,

>

> The short answer to you question is yes, there is considerable information

> on the PSA doubling time prior to any treatment.

> This comes out of the growing number of institutions following appropriately

> selected men defering immediate treatment for Active Surveillance.

> The most common approach is to suggest that a PSA doubling time of three

> years or less indicates that the cancer has become aggressive and needs

> treatment.

>

> However, nothing about our disease is simple.

>

> The most common criteria for deferring treatment include:

> PSA no more than 10.

> PSA density (PSA divided by prostate size from the biopsy ultrasound) less

> than 0.1 to 0.15

> No more than three cores in the biopsy positive for cancer.

> No more than 30 to 50% of any single core positive.

> No Gleason 4 pattern as the primary number.

>

> You and your husband should derive as much information as possible from the

> biopsy report in order to estimate his cancer stage and decided on a course

> of action.

> o How many cores were taken? Modern biopsies should take at least 12

> cores.

> o How many cores were positive for cancer?

> o How much cancer was there in each positive core?

> o What was the prostate size? The larger the prostate, the more PSA can be

> generated by benign tissue, not cancer.

>

> The biopsy indication of Gleason pattern 4 as the primary number in the 4+3

> may indicate a more serious cancer not appropriate for long-term avoidance

> of treatment. The Gleason information is so important that you should

> consider having the biopsy slides sent to an expert lab for a second opinion

> on the pathology. This is covered by most insurance. The lab that did his

> biopsy pathology can arrange this. Among the recommended labs specializing

> in prostate pathology are Bostwick and Epstein (s Hopkins). Bostick can

> also do DNA ploidy analysis to provide additional information on the cancer

> aggressivenes.

>

https://www.bostwicklaboratories.com/global/services/laboratory-services/second-\

opinions.aspx

> http://www.hopkinsmedicine.org/second_opinion/urology/index.html

>

> PSA is an important, but not definitive, biomarker for prostate cancer. To

> accurately estimate the doubling time one should have a series of PSA

> readings ideally spanning at least two years. The more the better. The

> number you provided suggest an erratic PSA history that could be due to

> prostate infection or inflammation as well as cancer. If you have more PSA

> values over time, one can calculate the doubling time. There are several

> web sites that will calculate PSA doubling times; the second one below also

> includes programs where you can include the PSA record and biopsy

> information to estimate the probability of cancer control with treatments.

>

> http://www.doubling-time.com/compute-PSA-doubling-time.php

> http://nomograms.mskcc.org/index.aspx

>

> I also have an Excel spreadsheet I could send you that plots PSAs over time

> and calculates the doubling time.

>

> However, given what you have provided, in your husband's shoes I would first

> get a second opinion on the biopsy pathology and look at all the information

> that can be gleaned from the biopsy. If there is significant (more than

> 30%) Gleason 4+3 in multiple cores, I would be giving serious consideration

> to treatment. Today there are a number of valid treatment options other

> than radical surgery.

>

> If the second opinion suggests that Active Surveillance may be an option,

> there is an abundance of information on those procedues, including color

> Doppler Ultrasound or MRI imaging to get more information on how much cancer

> may be present. If you decide to follow that route, I can provide a number

> of references. I've been doing Active Surveillance for five years and stay

> current on the medical literature.

>

> The Best to You and Yours!

> Jon in Nevada

>

> ==========================

> Question on doubling time

> Posted by: " LYNN " adopt4u@... luvmyrhett

> Sun May 29, 2011 10:16 am (PDT)

>

>

> My husband was diagnosed in January 2010 with a PSA of 7.4 and GS of 4+3. He

> is not really happy with any of his alternatives, so we have just been

> watching his PSA. In the last 18 months it went down to 6.5 and this month

> was at 9.96.

>

> My question is this: are there any statistics on doubling time of PSA when

> no treatment has been done? I could find statistics on doubling time of PSA

> and their relative outcomes for men who had their prostates removed, but

> nothing about men who were not treated.

>

> Do any you know where to look or what the mortality rate associated with

> doubling time is for non-treatment?

>

> Thank you so much.

> Lynn

>

[Guest guest]

LYNN wrote:

> My husband was diagnosed in January 2010 with a PSA of 7.4 and

> GS of 4+3. He is not really happy with any of his alternatives,

> so we have just been watching his PSA. In the last 18 months it

> went down to 6.5 and this month was at 9.96.

>

> My question is this: are there any statistics on doubling time

> of PSA when no treatment has been done? I could find statistics

> on doubling time of PSA and their relative outcomes for men who

> had their prostates removed, but nothing about men who were not

> treated.

>

> Do any you know where to look or what the mortality rate

> associated with doubling time is for non-treatment?

>

> Thank you so much. Lynn

Lynn,

Like everyone else in this newsgroup, I'm not a doctor. I have

no special expertise beyond that of a layman who has been treated

for prostate cancer and followed developments for some years.

I won't make any specific recommendation on whether your husband

should seek treatment or not. As you have seen, some patients

would and others would not. I'm in the " would " group myself, but

I understand those who would not.

One of the big problems in medical treatment is finding good

advice. Some doctors are not reliable and not worthy of trust.

Some just don't connect well with the patient and the patient

feels that the doctor isn't listening to him. Perhaps your

husband is turned off by the doctor as much as by the treatment

options.

It's extremely important to find a very good doctor. Basically,

a person gets one good shot at curative treatment. If the

surgery or radiation doesn't work, the follow on options are less

and less attractive and less likely, or completely unable, to

effect a cure.

Here is a list of National Cancer Institute " designated " cancer

centers. These are hospitals and clinics that NCI thinks offer

top quality care.

http://cancercenters.cancer.gov/cancer_centers/cancer-centers-names.html

If your husband is now on Medicare, he can probably get a

consultation and, if desired, treatment from docs at these

centers. Most of them are teaching hospitals where the doctors

have more knowledge of the latest research than most docs at the

VA or in private practice. This list might help you to find a

good doctor.

I would recommend seeing at least two docs, a surgeon and a

radiation oncologist, and getting advice from each of them.

Best of luck.

Alan

[Guest guest]

LYNN wrote:

> My husband was diagnosed in January 2010 with a PSA of 7.4 and

> GS of 4+3. He is not really happy with any of his alternatives,

> so we have just been watching his PSA. In the last 18 months it

> went down to 6.5 and this month was at 9.96.

>

> My question is this: are there any statistics on doubling time

> of PSA when no treatment has been done? I could find statistics

> on doubling time of PSA and their relative outcomes for men who

> had their prostates removed, but nothing about men who were not

> treated.

>

> Do any you know where to look or what the mortality rate

> associated with doubling time is for non-treatment?

>

> Thank you so much. Lynn

Lynn,

Like everyone else in this newsgroup, I'm not a doctor. I have

no special expertise beyond that of a layman who has been treated

for prostate cancer and followed developments for some years.

I won't make any specific recommendation on whether your husband

should seek treatment or not. As you have seen, some patients

would and others would not. I'm in the " would " group myself, but

I understand those who would not.

One of the big problems in medical treatment is finding good

advice. Some doctors are not reliable and not worthy of trust.

Some just don't connect well with the patient and the patient

feels that the doctor isn't listening to him. Perhaps your

husband is turned off by the doctor as much as by the treatment

options.

It's extremely important to find a very good doctor. Basically,

a person gets one good shot at curative treatment. If the

surgery or radiation doesn't work, the follow on options are less

and less attractive and less likely, or completely unable, to

effect a cure.

Here is a list of National Cancer Institute " designated " cancer

centers. These are hospitals and clinics that NCI thinks offer

top quality care.

http://cancercenters.cancer.gov/cancer_centers/cancer-centers-names.html

If your husband is now on Medicare, he can probably get a

consultation and, if desired, treatment from docs at these

centers. Most of them are teaching hospitals where the doctors

have more knowledge of the latest research than most docs at the

VA or in private practice. This list might help you to find a

good doctor.

I would recommend seeing at least two docs, a surgeon and a

radiation oncologist, and getting advice from each of them.

Best of luck.

Alan