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Home:
PCU1|2002:
Paul Schellhammer, MD, FACS
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Paul
Schellhammer, MD, FACS |
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Program Director, Virginia Prostate
Center of
Eastern Virginia Medical School and Sentara
Cancer Institute
Trustee, American Board of Urology |
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Edited comments by Dr Schellhammer
Editor’s note:
After a distinguished career in prostate
cancer clinical research, in 2000
Dr Schellhammer was diagnosed with the disease and treated with
a radical prostatectomy. Now, 18 month later, his PSA is rising
and he is contemplating various treatment options.
A personal perspective on prostate cancer
I attend to men with prostate cancer in situations very similar
to mine, and I try to calm their emotional upheaval. It did not
work in reverse. At first diagnosis, I was upset and fearful. I
was afraid — not of the treatment — but of the consequences
of subsequent failure such as a rising PSA, bone metastases and
death.
Three of 25 biopsies were positive with a high Gleason score (7-9).
My surgery went very well, and my prostate was removed without any
positive margins, seminal vesicle or lymph node involvement. If
the Gleason score had been one core of 3+3, then I may have considered
interstitial radiation. However, with a higher grade, the best current
algorithms would indicate interstitial radiation plus external beam
radiation plus hormonal therapy. I did not feel comfortable with
that combination.
At six weeks after surgery, I developed leg pain, fever and chills.
A CT scan revealed a psoas abscess — a rare complication associated
with radical prostatectomy — which was drained and treated
with antibiotics.
From the Mayo Clinic series of patients with high-grade disease,
I predicted a 40% to 60% chance of developing progression within
2 to 3 years. Throughout the first postoperative year, my PSA was
zero. At the one-year anniversary, my P S A was minimally elevated
at 0.09 ng/mL. Since then, my PSA has slowly gone up to 0.2-0.25
ng/mL. In the next couple of months, I will be receiving a short
course (6-9 months) of androgen deprivation (LHRH-agonist and bicalutamide),
radiation therapy and a taxane-based chemotherapy regimen.
I have never recommended chemotherapy to a patient in my situation.
Now that I have thought about it, rather than recommend — because
we don’t have the data — I now introduce chemotherapy
as a possible option. I suggest that the patient consult a medical
oncologist for at least a discussion. But that’s a new wrinkle
in my patient interaction.
In essence, I changed my practice as a result of this experience.
What made me change was the difference between actual reality and
the hypothetical situation. The hypothetical situation that I was
in before as a physician advising patients did not “put the
rubber to the road.” When you think about the issue personally
— I won’t say day in and day out — but every day,
you learn a little bit more.
Adjuvant hormonal therapy
Nine months after my surgery, results from the bicalutamide Early
Prostate Cancer (EPC) trials were announced. I asked, “If the
results are true for patients starting bicalutamide within one month
of surgery, what about patients who are within 6 to 9 months of
surgery?”
The medical oncologists claimed that one could not make that extrapolation,
and I decided not to initiate therapy. Had the results of the delay
in bone-scan progression been available at the time of my surgery,
I probably would have initiated bicalutamide 150 mg.
Gynecomastia was the major problem in the 100 men we enrolled
on the EPC trial. Those men in whom it was bothersome had liposuction.
There was no significant downside that would have precluded me from
taking bicalutamide, and the delay in bone-scan progression would
have been a worthwhile and significant end point.
Although the data is not yet mature, intuitively and hypothetically,
adjuvant bicalutamide may also affect mortality. In women with breast
cancer, adjuvant tamoxifen trials have demonstrated that survival
differences may take a long time to emerge.
I am now discussing the option of adjuvant hormonal therapy with
high-risk men with newly diagnosed prostate cancer similar to my
own.
Selected References
Amling CLet al. Long-term hazard of progression after radical
prostatectomy for clinically localized prostate cancer: Continued
risk of biochemical failure after 5 years. J Urol 2000;
164(1):101-5. Abstract
Blute MLet al. Use of Gleason score, prostate-specific antigen,
seminal vesicle and margin status to predict biochemical failure
after radical prostatectomy. J Urol 2001;165(1):19-25.
Abstract
Lau WK et al. Radical prostatectomy for pathological Gleason
8 or greater prostate cancer: Influence of concomitant pathological
variables. J Urol 2002;167(1):117-22. Abstract
Pound CR et al. Natural history of progression after PSAelevation
following radical prostatectomy. JAMA 1999;281;1591-7.
Abstract
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