Health Talk: Prostate Cancer
Hosted by Craig Stoltz
Washington Post Health Editor
Tuesday, May 23, 2 p.m. EDT
Today's cover story features an excerpt from Hamilton Jordan's book, "No Such Thing as a Bad Day." Jordan's book chronicles his three-time battle and associated victories with cancer, first with lymphoma, then with skin cancer, and his last battle with cancer of the prostate.
With prostate cancer so frequently in the media's spotlight--the last big public personality to be diagnosed being New York City Mayor Rudy Giuliani--more questions are raised about this illness. Dr. Mohan Vergese, urologic oncologist and Program Director at the Washington Cancer Institute, will be answering your questions and concerns regarding this disease.
Read the transcript below.
Good afternoon everyone. Thanks for joining us once again for Health Talk. Today we'll be talking about prostate cancer with our guest, Dr. Mohan Verghese. Let's begin.
At what age should men start thinking about prostate cancer prevention? What factors increase the risk for getting this type of cancer? I am a 25 yr. old man of good health - should I be concerned? I should also tell you that cancer does run in my family.
Dr. Mohan Verghese: At present there appears to be no proven preventive measures that one can take to prevent prostate cancer. There is some evidence that diets rich in animal fat predisposes a person to certain kinds of cancer. A healthy diet with minimal animal fat, NO smoking, and engaging in regular exercise is what one can do. You should start screening for prostate cancer starting at age 50 with a PSA test and DRE. If you have a family history of prostate cancer, this should start at age 40.
Is it possible for treatment of hypothyroidism (synthetic hormone) to cause an enlarged prostate and or elevated serum PSA levels?
Dr. Mohan Verghese: As far as I have read, no.
That Hamilton Jordan story was interesting. Does someone with cancer have a higher risk of having a second cancer? Is there a general susceptibility to cancer, or is the risk attached to a specific kind?
Dr. Mohan Verghese: Not necessarily. There are some cancers that may increse the risk for others. Definitely lifestyles such as smoking puts a perso'ns risk for developing cancers at multiple sites such as lung, bladder, kidney and even prostate
My father was diagnosed with prostate cancer. He had surgery, then radiation. The radiation made him feel awful--he really didn't want to live anymore, and was ordinarily an upbeat person. Eight months later he died (not of cancer). I often wonder if it would have been better for him to forego the radiation. Would he have at least had a better quality of life had he not? I thought prostate cancer was slow-growing.
Dr. Mohan Verghese: You have stated a problem that physicians face on a daily basis, especially in prostate cancer: is the cure worse than the treatment? It appears that your father did not tolerate therapy and it did alter his quality of life to a great extent. In hindsight we can say that he should not have been treated. Prostate cancer is a RELATIVELY slower growing tumor compared to others. However if left untreated it can cauuse problems in patients who have a greater than 5 -10 year life expectancy
Daughter in Washington, DC:
My usually healthy father was daignosed with prostate cancer about a year ago (he's 60) and underwent extensive surgery for it. (I don't quite know the extent of it, my parents were afraid to tell my sister and I because it was so severe.) He chose the surgery over chemotherapy because of its success rate. How often are these surgeries successful, and what is the mortality rate of this illness?
I am, obviously, quite worried about him, even though from what I've read and heard, prostate cancer is one of the most treatable. Additionally, he has gone back for testing and the cancer seems to have "disappeared," at least for the time being.
Dr. Mohan Verghese: Your father's decision to have surgery at this time is appropriate. He is disease free at this point. I need lot more information to answer the rest of the question. I think from what I have gathered he should do well in the long run. There are many effective treatments if the disease recurs that should give him a good quality of life. If he remains disease free beyond 5 years or longer, his life expectancy should be equal to the general population.
Do you think all men over 40 should get PSA tests? I'm told that it has so many false positives and negatives and that it's not really worth it.
Dr. Mohan Verghese: All men with family history of prostate cancer should get screened starting at 40. The evidence shows that screening with PSA allows the cancer to be detected earlier thereby allowing for a greater chance of cure. Recent reports of a decreasing death rate from prostate cancer for the first time may be attributed to a great extent on the outcomes of PSA-based screening. I believe you should be screened yearly. It however is your decision.
Men need to mobilize around prostate cancer and lobby and publicize it and have fund-raising walks the way women have done with breast cancer. There is so much more awareness about the latter. But the problem is that men don't want to acknowledge this particular weakness, as if by ignoring it, it won't happen to them. Your thoughts? By the way, are you related to Dr. Abraham Verghese? I just bought his book "The Tennis Partner" recently, but have not read it yet. I hear it's very good.
Dr. Mohan Verghese: You are absoloutely right in that funds for research in prostate cancer lags far behind breast cancer, AIDS etc. I think the reluctance is slowly decreasing in men overall which is my imoression over the last 10 years, thanks to the awarenes in the public. Dr. Abe Verghese and I come from the same town in Kerala, India and we are good friends. Yes, I have read the book and it is an excellent one.
As for the feared prostate exam, is the doctor checking to see if the gland is soft? Is that all there is to it as long as the PSA clear? Sounds too easy, but not painful.
Dr. Mohan Verghese: Yes. The combination of digital exam and PSA gives the highest detection rate for early stage disease. If one opts for the blood test alone, it may be normal in a fourth of patients.
I'm surprised it's taking Giuliani so long to make a decision about treatment. Don't people usually figure out to do in a few days?
Dr. Mohan Verghese: Ther are a number of options for treatment of prostate cancer. Each treatment has its benefits and risks that may change a persons quality of life.I think it is important for all patients diagnosed with this disease to think through the options and make an informed decision however long it may take that person.
About 1 year ago my father (age 73) was diagnosed with hypothyroidism and began a synthetic hormone treatment. In that year's period his PSA levels went from 2.4 to 6.2ng/ml. Can secondary hormones, such as testosterone, be effected by a synthetic thyroid hormone, and do you know of any correlation between hypothyroidism and prostate cancer? Thank you in advance for your response.
Dr. Mohan Verghese: There is no correlation between prostate cancer and hypothyroidism. I am unaware of PSA rise on replacement therapy. I will be glad to research that and let you know if you want to call me or email me. I would recomend that your father be closely monitored.
Dr. Verghese, I'd like you to clarify something from an earlier answer. Does the PSA test give a false OK to 25 percent of the men who really have some cancer? That strikes me as a high rate of failure for such a widely used test. . . .
Dr. Mohan Verghese: PSA is used strictly to screen men for prostate cancer. A normal PSA and a normal rectal examination tells a physician that the risk of clinically important prostate cancer is very low. Serial yearly screening by PSA, showing a rising level, even though the levels are in the normal range increases the probability of harboring cancer. For instance PSA in 98 is 2ng/ml. In 99 it is 2.9ng/ml and in 2000 is 3.4ng/ml with a normal exam. This rise in PSA is indicative of a strong possibility of cancer even though the levels are normal.
A PSA value between 4 - 10 ng/ml indicates PCA in 30 - 35% of patients. The higher the PSA level, the higher the probability of PCA. PSA is the best tumor marker that we have though the sensirtivity and specificity of this test is not as high as we would like it to be. The point I want to convey is that it is a combination of PSA and DRE that increases the detection rate. Most cancers detected and cured are made with a PSA alone than with a normal Rectal Examination.
How is prostate cancer treated or viewed in other countries, beside the U.S.?
Dr. Mohan Verghese: Countries that have resources view it very much like we do here.
After brachytherapy and external beam radiation treatment, PSA has reached a nadir of <0.2. If it rises, at what point would further treatment be indicated?
Dr. Mohan Verghese: You are the ideal patient that has responded to treatment, having achieved a low PSA. You need to evaluated with regular check ups. It is difficult to anwer your question with out other parameters.
Is the incidence of prostate cancer going down? It seems to me so many people in the public eye have it, it must be increasing.
Dr. Mohan Verghese: The peak incidence was achieved in the early 90s with the use of PSA used as screening.
Well, we're out of time for this afternoon. Dr. Verghese, thanks so much for taking the time to handle our readers' questions--this is indeed part of that effort you and a questioner mentioned to help raise awareness about the disease. And thanks everyone who wrote in with questions and comments; today's high volume of messages prevented us from getting to everybody. We'll see you all again next week at 2 p.m. on Tuesday for another session of Health Talk, when our topic will be that perennial favorite, weight loss and nutrition. Meantime, you men over 40 with risk factors, and all men 50 and above? You know what you have to do. Pick up the phone and make an appointment.
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