Treatment

[Bil-R]

  I'd like some suggestions about PC treatment.  Here's the story:
  55 y/o otherwise excellent health
  PSA - 4.0; free PSA - 5 percent
  Needle bx: Gleason 2+2=4; right side only; TRUS negative.
  Questions:
  1.  What additional tests/scans should be done before surgery?
  2.  Should other treatment options be considered?
  3.  Autologous blood donations?
  4.  Hormone treatment before surgery?  Prostate is 19.65 cc.
  5.  Wise to have surgery right away or possible to wait until mid-December?
  6.  Heard it was unwise to do surgery within two months of needle bx.  Is this true?
  7.  Survival rate?
  8.  Chances of regaining full sexual potency without artificial aids?  (Assuming nerve-sparing.)
  9.  Any benefit in test for p27 protein?
  10.  Importance of use of "CaverMap"?  (www.fda.gov/fdac/features/1998_pros.html)
  11.  Effect of RP on orgasm?
  12.  How long will I be disabled from normal daily activities?
  Thanks,  Bill R.

[hfhs M.D.-AK]

Dear Bill,
I will attempt to answer all of your questions directly in my response to your question, but you said it yourself, you are a healthy 55 year old with prostate cancer detected at a low stage.  Both your PSA and Free PSA are in high risk ranges, and are why your doctor wanted you to have a biopsy.  The biopsy results show a low grade of prostate cancer, one that is usually confined within the prostate gland.  There are other tests that we run on people with higher PSA or symptoms suggesting metastatic spread, but you do not fall into this category.  The amount of information at this time is sufficient for some type of intervention.  Due to your health status and the high probability of organ confined disease(no spread), I would initially recommend surgery.  Your other options include radiation therapy(external-bean or seed implantation), cryotherapy(freezing the prostate), hormonal therapy or watchful waiting(following the PSA periodically).  I think most urologist would recommend surgery or one of the other intervention procedures.  I don’t think watchful waiting would be a good treatment in your case.
If you chose to pursue a surgical intervention, Retropubic or Perineal, autologous blood donation is a reasonable option.  This allows you to donate your own blood before surgery such that if you need blood after surgery you are getting your own.
Hormone treatment before surgery is used to downstage a tumor(shrink) to increase the chances of organ confined disease and facilitate a successful resection without positive margins.  I would not recommend this therapy in your case do to the high probability of you having organ confined disease.  The hormone shots do have side effects which are not always tolerated by everyone.
Nobody can tell you when to have your surgery.  The way you can look at this decision is by maximizing your chances of a successful operation.  Since the risk for non-organ confined disease is low, according to your numbers, you and your doctor want you to have the best possible outcome.  The sooner the surgery is done the less the chance of spread.  I think waiting is a calculated risk that only you as the patient can make.
You can have the surgery done at any time after your diagnosis.  Waiting two months after biopsy may allow for the swelling and inflammation to cool down facilitating an easier operation, but usually, there is sufficient time after the biopsy, after the consultation and discussion and donation of blood that a few weeks have passed.
In regards to sexual potency after surgery, assuming they had no problems before surgery and a good anatomical dissection was done sparring the nerves, I tell my patients you have a 50, 50 shot.  As you stated in this portion of the question, there are other erectile aids to help with this complication, if it is a problem after surgery.  Remember, the most important thing to spare in this surgery is your life.  Your surgeon will sacrifice the nerve on either side if your cancer is any where near it.  There should be little effect on your ability to reach orgasm.
Protein p27 is an inhibitor of the cell cycle with potential tumor suppressor function.  Decrease levels of p27 have been shown to correlate with poor outcomes in colon and breast cancer.  Recently a study relapsed I the Journal of Urology out of UCLA did show a correlation between outcome and levels of p27 however this is not a widely available test.  Also it ability to predict prognosis was best in stage T2 and T3 patients which I don’t think you are apart of.  You really didn’t say if your rectal exam showed a nodule.  I would not worry about this test.
I don’t know what you are referring to when you say Caver Map.  I did a literature search and could not find anything.  It is not listed in the two main urology text books.  I think any map of the prostate is important, but a good anatomical dissection should be able to be performed by most urologists.
Depending on which type of surgery you have, you can expect to be  out of work for at least a month and not back to your normal activities for 4-6 weeks.  It is important to resume your activities after surgery and you can use pain as your guide.
I hope I have answered your questions and help you a little.  Try not to focus on the new experimental work that is coming out and focus more on your overall good prognosis from the stage and grade of your prostate cancer.  Good Luck!
This information is provided for general medical educational purposes only.  Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition.  More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).
Sincerely,
HFHS M.D.-AK
*keyword:Prostate cancer