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Program Supplement
INTERVIEW WITH DR PAUL SCHELLHAMMER
DR NEIL LOVE: Welcome
to Prostate Cancer Update. This is medical oncologist Dr Neil Love.
I am partnering in this exciting educational initiative with my
colleague at the University of Miami, urologist Dr Mark Soloway.
Our goal is to provide you with the perspectives and insights of
prostate cancer research leaders, and specifically to address the
practical clinical questions that come up in everyday practice.
Later on in the program, I'll also review an exciting new patient
preference research project that Mark and I are launching this summer.
We'll be seeking your assistance and participation in this endeavor.
In order to address the very pressing day-to-day patient care issues
of clinical practice, this audio series will utilize case discussions,
including many of the patients Mark presents in his annual, "Challenging
Cases in Urology" meeting in Miami every winter. Before that,
a case presentation we think you will agree provides a very different
perspective on this disease - a 62-year-old man who presented with
a PSA elevation. What makes this patient somewhat unusual is that
his entire professional career as an urologist and researcher has
focused on prostate cancer. Dr Paul Schellhammer presents his own
case.
DR PAUL SCHELLHAMMER: Like I hope most urologists,
who preach the issue of PSA, I had been obtaining a PSA yearly since
I was 50 years of age. I had a very "normal" value that
was stable at around a2 to 2.5. I missed a year and a half because
of a cardiac event, and lo and behold the next PSA was elevated.
I had, interestingly, been on Proscar for some lower urinary tract
symptoms, so when I did the multiple factor the true PSA was 5 to
6. A repeat confirmed that, and I was very convinced that I did
have prostate cancer. I asked my associate to do more than the usual
six or ten biopsies, because I really didn't want to come back for
a second, third and fourth review.
DR LOVE: What were
your thoughts when you saw that PSA?
DR SCHELLHAMMER: It was interesting because I
often attend to men with very similar numbers, and try to calm their
emotional and visceral upheaval. But the same comforting words that
I tried to address them with didn't work in reverse. In other words,
they didn't work on me. I was upset. I would even say, a bit fearful,
as well.
DR LOVE: What exactly
were you afraid of?
DR SCHELLHAMMER: Interestingly,
not the treatment. Really, not the treatment, but the consequences
of subsequent failure.
DR LOVE: Specifically
what?
DR SCHELLHAMMER: Rising PSA, bone-positive disease
and then death from prostate cancer. There's no doubt that is a
minority circumstance. Seeing 50, 60, 70 patients a week with prostate
cancer, although the difficult and the severe cases are in the minority,
they still burn the image in your mind. I found that I looked at
each of the failures with greater memory retention than the successes
that came in greater numbers. But I guess that's the pessimism that
sometimes creeps into the human mind.
DR LOVE: Can you
talk about the details of the biopsy? What it showed? And what kind
of treatment you decided to have?
DR SCHELLHAMMER: Well, I decided to have a lot
of biopsies, 25 in number. Interestingly enough, three of the 25
were positive. That certainly doesn't speak to a great volume of
disease and probably would have been missed on the routine one or
two go-rounds. But, also interestingly, the grade was relatively
high. That indicates that you don't have to have a high PSA to have
a high Gleason grade. In my mind, having dealt with surgery, having
a surgical mentality and not being particularly perturbed about
the issues involved with an operation, specifically with the grade
and the fact that I was optimistic about my cardiac status, I felt
that surgery was the best treatment for me.
DR LOVE: So that's
what you went through?
DR SCHELLHAMMER: The surgery that I had went
very well. I actually took a cross-country plane trip five days
after the surgery. I was ambulatory, and doing virtually everything
that I thought I'd be unable to do at one week. So I would say the
post-operative course was quite reasonable. Interestingly enough,
though, at six weeks, I began to develop some leg pain. I thought
it was some tendonitis. It is interesting because thinking back
it was clearly psoas irritation symptoms and I developed fever and
chills. CT scan showed a psoas abscess, which is a pretty rare phenomenon
these days. In fact, I brought up the literature, and there hasn't
been a psoas abscess associated with a radical prostatectomy for
a decade or more. Fortunately, with modern medicine - CT-guided
drainage and antibiotics - I was cured and didn't need a secondary
operation. But, as I tell patients, complications are possible even
with an operation that apparently goes beautifully, which this operation
did.
DR LOVE: Can we talk
a little bit about your pathology? Specifically, what your pathology
was and what you interpreted it to mean in terms of your prognosis?
DR SCHELLHAMMER: Well, as many have advised,
you should have more than one person look at your pathology. I had
more than one, and they were experts, but the Gleason score ranged
from 4+3, with a little bit of 5 to a lot of 4 and 5, with a little
bit of 3. But anyway, it was certainly 7, 8 or 9, which is not a
happy circumstance with regard to grading.
The prostate itself was removed without any positive margins, and
without any seminal vesicle. The lymph nodes were negative. So,
from that standpoint, it was a good operation. If the Gleason had
been one core of 3+3, I might have considered interstitial radiation.
I do that procedure with my radiation oncologists frequently enough,
and I've followed patients who've done very well. With a higher
grade, it would have meant interstitial radiation plus external
beam plus hormonal therapy, according to the present best algorithms.
I didn't feel comfortable with that combination. As I said, the
surgical procedure didn't concern me or worry me. The anesthesia
didn't concern me or worry me. I wasn't particularly concerned about
the continence issue and sexual function. I was willing to accept
that it wasn't going to be optimal no matter what I had, if I had
radiation with hormone therapy. So, that was not a major issue.
DR LOVE: Do you want
to talk about what happened in terms of sexual function and urinary
control?
DR SCHELLHAMMER: Yes. Urinary control, I've learned,
is a relative factor. If you ask me specifics about leakage and
pads, I would give you one answer. If you ask me if I have any problem
or incapacity, I'd give you another. Namely, I have no problem,
incapacity or limitations, but my urinary control isn't what it
was pre-treatment. It's interesting, as men have said to me, it's
a little worse at the end of the day. It varies from one day to
another. I've described it as being like a basketball player who
one day is in the zone and can't miss. Some days I'm dry as a bone
and other days I really need a pad.
DR LOVE: How much
does the urinary situation bother you? Is it a major problem?
DR SCHELLHAMMER: It doesn't bother me at all.
In fact, I will tell patients to some degree, not to influence them,
but I would much rather be in my circumstance then to be dry, but
have to run to a commode every 45 minutes to an hour because of
irritative symptoms. So, I guess that varies depnding on the personality.
Some folks are very fastidious and the least drop of urine is upsetting.
But, from practical time factor circumstances, I'm as good as anybody
else.
DR LOVE: How about
sexual function?
DR SCHELLHAMMER: I have some sexual function
with the aid of Viagra and with the use of the ring, which I didn't
realize in times past is very useful for preventing leakage during
sexual activity. So, I tell patients now to use the ring not only
to maintain the erection, but also to prevent any leakage, which
was always worrisome, embarrassing and kind of upsetting in the
sexual act. So, there are ways to help out - pump, Viagra, ring
and so forth.
DR LOVE: Now, after
you had your surgery and you evaluated where things were heading,
did you consider hormonal intervention at that time?
DR SCHELLHAMMER: After the surgery?
DR LOVE: Mm-hmm.
DR SCHELLHAMMER: No, because the criteria that
I would have used for hormonal intervention would have been positive
nodes or seminal vesicle involvement of significant degree. With
neither of those being present, I did not consider that.
DR LOVE: When you
sat down after the surgery did you actually try to come up with,
in your mind, a number as to what the chance was that you were going
to develop progression in the future?
DR SCHELLHAMMER: Well, I knew the number was
50 percent, plus or minus 10, from the Mayo Clinic series and other
large series that looked at high-grade disease within five years,
probably within two to three.
DR LOVE: Now, you
said that that really didn't meet the criteria that you would use
to offer hormonal therapy at that time, 18 months ago. Do you still
feel the same way now, 18 months later, with the Early Prostate
Cancer data, the Casodex data out?
DR SCHELLHAMMER: Well, that's an interesting
question, because I was about nine months out when that trial first
was analyzed and the results became known. I was at these conferences
where that information was coming out, and I did ask the question:
Well, if that's true for starting a month after the surgery, how
about someone who's six months or eight months after surgery?
The medical oncologists would say you can't make that extrapolation,
that leap, that you can then transfer that information. So, effectively,
I used that information not to initiate therapy later. Now, if that
had been known straight away, I think I would have given it strong
consideration. If the results of that trial were known straight
away and I had a high-risk, knowing that the trial, with its high-risk
group, prevented or delayed progression, bone scan progression and
so forth, I probably would have initiated it.
We entered 100 patients on the EPC trial, so I have experience
with the outcome, which is tremendously variable. Obviously, you
don't know who's on placebo and who isn't. But gynecomastia certainly
is a significant player in the role. Other than that, I didn't see
major difficulties. And the men who had gynecomastia, a couple for
whom it was bothersome, had liposuction, which worked very well.
So, in my mind, I don't see any significant downside that would
have said to me I will not take this therapy.
DR LOVE: So, you
don't think the effects on the breast would be enough that it would
be a significant deterrent for you?
DR SCHELLHAMMER: No, because I'd have liposuction,
if it were, and get rid of it.
DR LOVE: On the benefit
side of the equation, if you were to consider 150 milligrams of
Casodex, what would you be expecting or thinking?
DR SCHELLHAMMER: Probably delaying progression
to bone. Casodex 150 as an adjuvant was shown to delay time to progression,
so that's a worthwhile end point.
DR LOVE: We don't
have enough data right now in terms of events to know whether or
not Casodex would affect mortality. If you were to try to hypothesize,
would you expect that there would be an effect there? Or you just
wouldn't know?
DR SCHELLHAMMER: I wouldn't know. But I would
hypothesize and intuitively think that there would be. The tamoxifen
trials in women have shown it takes a long time to gather the events,
and so the early outcomes may not deliver the mortality or survival
differences that the long-term follow-up does.
DR LOVE: I guess
the three potential benefits that have been discussed are delay
in PSA failure, delay in clinical progression and improvement in
survival. Having been through the experience as a patient, do you
think that, for example, delaying progression without an effect
on survival, would be an important benefit that you would value?
DR SCHELLHAMMER: Yeah. The delay in PSA progression,
to me, wouldn't be that significant from the physical standpoint.
From an emotional standpoint, it's nice to see zero PSAs. The delay
in time to clinical progression to bone, which is the usual, to
me would translate into a benefit, which I would hope would then
translate into a survival benefit, as well. If there was absolutely
no survival benefit, I'd still like to delay the progression to
bone.
DR LOVE: Now, can
you talk a little more specifically about what happened with your
PSAs?
DR SCHELLHAMMER: They were zero through one year.
Then, on about the one-year anniversary, there was a minimal elevation
by the hypersensitive assay. That would still be considered undetectable,
but it was .09, and it was different from the three zeros I'd had
before. It has just gone up very slowly to roughly .2-.25.
It's interesting, I've also recognized that, depending upon what
series you read, the time from post prostatectomy to a PSA rise
is critical, or at least informative with regard to local failure
versus distant failure with regard to benefit of radiation versus
perhaps less benefit of radiation. There are certain time points
- one year, 18 months, two years - but series vary tremendously
as to the cut point that they have a PSA that's undetectable, and
the more you go back, the higher the PSA is. So, it wasn't too many
years ago that .4 was the cut point. Mayo Clinic still feels that
that's reasonable. Then .2 became the cut point, and then .1. Some
places use .07. So, obviously, the time it takes you to go from
.07 to .4 might be significant, and you can't put yourself necessarily
in the study's time chronology without knowing clearly the PSA they
used as detectable versus undetectable.
DR LOVE: In terms
of this particular moment in time, what are you thinking? Are you
thinking about some kind of intervention?
DR SCHELLHAMMER: Yeah, I'm going to undoubtedly
begin some form of androgen deprivation therapy and have radiation
therapy. That's traditional. The question in my mind is when to
interact with the chemotherapy agent. Some would say that that's
precipitous and too drastic, but with the histology being what it
is, I guess I'm of the mindset to hit it hard for a period of time,
and then sit back and see what happens.
DR LOVE: So, when
do you think you're going to be doing this?
DR SCHELLHAMMER: The next couple of months.
DR LOVE: And you're
saying you're going to go for both radiation therapy and androgen
deprivation?
DR SCHELLHAMMER: To me, there are two aspects
with regard to androgen deprivation. There is volume reduction,
which we know it does know well. So, if you have a big prostate,
you want to reduce it to some degree and get the benefit. Then there's
the synergy aspect that some folks agree with and some don't. I
kind of like the idea that there's synergy. So, if I'm going to
have radiation, why not synergize it with some short course of androgen
deprivation? But I don't mean six to nine months.
DR LOVE: Specifically,
what?
DR SCHELLHAMMER: An LHRH analog and Casodex.
DR LOVE: So, you'll
take both?
DR SCHELLHAMMER: Yeah.
DR LOVE: You're also
thinking about receiving chemotherapy?
DR SCHELLHAMMER: Yes.
DR LOVE: Which chemotherapeutic
regimen or agent?
DR SCHELLHAMMER: A taxane-based regimen.
DR LOVE: When you
look at this plan that you're thinking about embarking upon, is
this a plan that you've used for your own patients?
DR SCHELLHAMMER: No. But that's an interesting
point because now when I see these patients, I have a dilemma. I'm
advising to them standard care, which would be hormone therapy,
radiation or radiation therapy alone. And you go through that, but
as far as the chemotherapy, I will be frank in saying that I, personally,
have never recommended chemotherapy to a patient in my situation.
I have, now that I've thought about it, introduced, rather than
recommended because I think we don't have the information to make
that statement, but I introduce that as a possible idea. And I have
them see a medical oncologist for at least an introduction. But
that's a new wrinkle in my patient interaction.
DR LOVE: So, you've
really changed your practice as a result of this experience you've
had?
DR SCHELLHAMMER: I think so.
DR LOVE: Why? What
happened that made you change?
DR SCHELLHAMMER: Well, I guess what made me change
was the difference between actual reality and the hypothetical situation.
The hypothetical situation that I was in before didn't put the rubber
to the road and make me think about, really, what am I going to
do? It made me say, this is probably what I'd do, and that sounds
reasonable, and that's what most people do, and there you go. But
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. You hear a
bit more. You hear with a different sensitivity. And so before,
if a medical oncologist, who is on the cutting edge said, I think
chemotherapy is a good idea, you'd say, I've heard that before and
where's the evidence? Now if he says it's a good idea, you say,
maybe I ought to think about it.
DR LOVE: Well, I
think it's a theme that we've seen in all parts of cancer medicine,
if you really look for it. It makes sense that the patient with
cancer is much more focused on the threat of the cancer than the
physician is.
DR SCHELLHAMMER: Mm-hmm.
DR LOVE: That is
natural since they are experiencing it. They're dealing with it.
I guess the issue is maybe whether or not you bring up options to
patients. Not necessarily recommendations, but options. What I hear
you saying is that maybe this experience has caused you to present
more options.
DR SCHELLHAMMER: Definitely.
DR LOVE: What about
the issue now, as you face men who are being diagnosed for the first
time with prostate cancer, particularly men who have similar, let's
say, situations to you at diagnosis, what options are you discussing
with them? Are you raising the option of early hormonal therapy?
DR SCHELLHAMMER: Absolutely.
DR LOVE: And if the
patient, again, a patient who's in your situation, turned to you
and said: Do you think I should do this? What would you say?
DR SCHELLHAMMER: I'd say we have evidence, clinical
trial evidence, that it does this. I would point out that the 42-percent
reduction has to be taken in the context of the absolute numbers,
which is 13 percent to 9 percent, so don't think 42 percent sounds
dramatic. It's significant. You know, don't over-blow the issue.
This is the circumstance. It's statistically significant. It could
translate into a benefit, survival benefit. All we know is this
now. And leave it at that.
DR LOVE: How disturbing
has it been for you to see your PSA elevate?
DR SCHELLHAMMER: Well, the first one was very
disturbing, and each one after that becomes progressively less.
Kind of like most things in life, you learn to accommodate. You
get less upset about it, and you kind of anticipate certain circumstances,
and you're happy that they're not happening yet.
DR LOVE: What do
you think has helped you cope with this from the beginning?
DR SCHELLHAMMER: Good family, solid family support,
a conviction in a life beyond the one we now have, in whatever form.
And the recognition that, undeniably, we're all headed to the same
end point, and one year, four years, five years, ten years is a
relatively small amount. I've had a good life up to now, and I don't
- I'm not going to say I don't fear the consequences of this, but
I don't get panicky about it anymore.
DR LOVE: What's your
life like now? Are you as happy as you were before this?
DR SCHELLHAMMER: Yeah. Definitely.
DR LOVE: Do you see
things differently at all?
DR SCHELLHAMMER: I've heard many cancer patients
say - and I didn't appreciate it as much - that it actually opened
up the doors of life. It made situations to be valued more apparent
and just increased their acuity, their sensitivity to a number of
issues. And I think that's undoubtedly the case. You just put -
the issue of the absence of life is put before you in a real and
forceful way, and your mind readjusts to looking at it. Now, you
don't dwell on it. You don't every waking minute, or even every
day, say, Oh - but you have looked the issue, you might say, in
the eye, and you've changed your appreciation for what you have.
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