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Introduction to Indigo


By Mark Scholz, MD

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Introduction to Indigo


By Mark Scholz, MD

Over 50,000 men relapse after surgery or radiation each year. The characteristics of Indigo are: previous treatment with surgery, radiation or cryotherapy, a clear bone scan, a normal level of testosterone in the blood, and one or more of the following:

  • A rising PSA due to progressing cancer. 
  • Residual disease after surgery noted on a pathology report, such as a positive margin or seminal vesicle invasion.
  • Residual disease after radiation or cryotherapy detected by imaging or biopsy.  
  • Surgically-detected or scan-detected cancer in the pelvic lymph nodes.  

Low-Indigo is the situation where microscopic lymph node metastases are very unlikely. Basic-Indigo is when microscopic pelvic lymph node disease is more likely. High-Indigo means that node metastases are unequivocally confirmed by surgery or scans. 

The traditional approach to Low-Indigo utilizes a sequential, one-treatment-at-a-time policy. It begins with radiation administered to the prostate fossa alone. If the cancer later resurfaces, the next step has traditionally been to start testosterone inactivating pharmaceuticals (TIP). Indigo can be controlled for a decade or more in this manner using ongoing TIP given either intermittently or continuously. 

Over the last 5 to 8 years, due to improvements in radiation technology, it has become feasible to safely extend the radiation field to cover the pelvic nodes. Therefore, men with Basic-Indigo or High-Indigo are now candidates for a multimodality approach that relies on extended radiation fields, supplemental TIP, and possibly chemotherapy to improve cure rates.


Mark Scholz, MD is the executive director of the Prostate Cancer Research Institute. He is also the medical director of Prostate Oncology Specialists Inc. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is co-author of Invasion of the Prostate Snatchers.  He has authored over 20 scientific publications related to the treatment of prostate cancer.

 

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Introduction


By Mark Scholz, MD

Introduction


By Mark Scholz, MD

Once the proper Stage of Blue is assigned (Chapter 1), the different treatments appropriate for that Stage can be considered. Overall, there are four broad categories of treatment available for prostate cancer: observation, local treatments, systemic treatments, and combination therapy.

Observation

Observation, commonly known as “active surveillance,” is the process of monitoring the cancer while reserving medical intervention until some aggressive behaviour is detected.

Local Treatments

Strategies that focus treatment on the prostate gland are called “local” treatments. Examples are surgery, radioactive seed implantation, varieties of external beam radiation therapy (IMRT, Proton, SBRT), and cryosurgery.  In addition, “focal” treatment options have been developed in which only a subsection of the gland is treated.

Systemic Treatments

The main danger from prostate cancer is the possibility of cancer spreading outside the prostate. Men with metastases (or potential microscopic metastases) require systemic treatment that circulates through the blood and treats cancer throughout the whole body. Examples of systemic treatments are hormonal therapies, chemotherapy, immunotherapy, and Xofigo.

Combination Therapy

When a local treatment is combined with a systemic treatment, or if multiple systemic treatments are used at the same time, it is called “combination therapy.” When combination therapy is being considered with the goal of improving survival, the survival advantages need to be balanced against the potential for greater side effects.


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Accessing the Medical Chart to Assign a Stage of Blue


By Peter Scholz

Accessing the Medical Chart to Assign a Stage of Blue


By Peter Scholz

Many treatments have irreversible consequences, so it is worth doing it right the first time. It is commonly understood in medical circles that long-term survival is improved by receiving optimal treatment up front. The first treatment is your best shot at eradicating the cancer. The initial step in the selection process is to determine your Stage of Blue.

First, obtain a copy of your medical records. You have every right to obtain and keep your records. Some offices may charge a small fee for providing you with the records. There is no universal format for charts, and some offices keep more complete records than others. It may be necessary to request the information from more than one doctor’s office to compile all the necessary information. You don’t need a complete understanding of everything in the chart. However, there are certain specific items you need to look for: 

Prostate Specific Antigen (PSA) Chronology: Construct a chronological history of every PSA measurement that has ever been taken and the date that it was performed. The PSA results can be found your Lab Reports. The testosterone level is also found in this section of the chart.

Clinical Stage: Information about the digital rectal examination (DRE) will be found in the Progress Notes section of the chart. Results indicate whether a nodule can be felt by the doctor’s finger. The type of nodule that is felt is recorded as the “T” stage. The doctor records his impression of the DRE in the Physical Examination section of the Progress Notes section of the chart per the following table:

T1:    No tumor is felt

T2:   Tumor feels confined within the prostate

T2a: Tumor that can be felt but involves 50% or less of one lobe

T2b: Tumor felt involving more than 50% of one lobe but not both lobes

T2c: Tumor felt in both lobes

T3:   Tumor felt that extends through the prostate capsule

T3a: Extracapsular extension is felt

T3b: Tumor felt that invades seminal vesicle(s)

T4:   Tumor felt that invades rectum or bladder

 

Radiology Reports (imaging studies): The radiology reports will be found in the Radiology section of the chart. Look for the Impression section of the report where the doctor who wrote the report summarizes the essential aspects of the scan results.

Biopsy Report:  The biopsy report will be in the Pathology section of the chart. For each of the biopsy cores that contain cancer, you should make note of the Gleason score and the percentage of the core that contains cancer. 

Finding Your Stage of Blue with The Quiz

The above information from your medical chart provides the data required to assign a Stage of Blue. The formula calculates your Stage by summing up the numbers written in response to the questions in the following quiz. 

The five pages that follow explain the basic components of the Stages of Blue—PSA, Gleason score, prostate scans, and body scans. Although the Stages of Blue can serve you perfectly well without all these background fundamentals, the goal of this book is to introduce basic vocabulary and thought processes that are utilized throughout the prostate cancer world. Becoming familiar with this information will take the level of conversation with your doctor to a higher level.


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Peter Scholz is the creative director of the Prostate Cancer Research Institute (PCRI). He received his B.A. in english literature from the University of California, Los Angeles. In addition to branding, design, and media production for the organization, his interests at PCRI are in simplifying, curating, and presenting prostate cancer information in ways that are understandable and accessible to patients. 

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The PSA Blood Test


By Stanley Brosman, MD

The PSA Blood Test


By Stanley Brosman, MD

PSA plays a variety of roles, the most familiar being screening to detect prostate cancer at an early stage. PSA also helps to define the Stages of Blue. Another role of PSA is to detect cancer relapse after surgery or radiation. Lastly, rises or declines in PSA after hormone therapy or chemotherapy help determine whether a treatment is working. 

 

Prostate Cancer Screening is Controversial

PSA screening often leads to the detection of small, essentially harmless cancers. However, doctors and patients frequently overreact, rushing into unnecessary radical treatment. Overtreatment of tiny cancers became such a big problem that in 2011 a government-sponsored team of experts, the U.S. Preventative Services Task Force, issued a warning against routine PSA screening. This recommendation was recently modified, acknowledging the possible value of PSA screening in well-informed patients.

 

Scans Measure the Size of the Prostate

Imaging with ultrasound or MRI improves the accuracy of PSA. Many men run high PSA levels from a condition called BPH that is totally unrelated to cancer. BPH is benign enlargement of the prostate gland, a common phenomenon associated with aging. The main issue is that PSA increases as the gland enlarges, but this rise in PSA has nothing to do with cancer.

 

There is a specific method for determining when the PSA is elevated higher than what would be expected for an enlarged prostate. It works by determining the prostate size in cubic centimeters(cc) using imaging (Chapters 4 and 5) and dividing the size by 10. For example, a noncancerous 30cc prostate should have a PSA of around 3.0; for a noncancerous 50cc prostate the PSA should be around 5.0.  A man’s PSA with a 100cc prostate will be approximately 10.  PSA is only abnormal (the official term is a “high PSA density”) when it’s 50 percent higher than would be expected, based on the prostate’s size. For example, a man’s PSA is abnormal if he has a 30cc prostate and his PSA is above 4.5.  An abnormal PSA for a 50cc prostate is above 7.5.  For a 100cc gland, PSA would need to be above 15 to be suspicious.

 

PSA Density

Doctors use a less intuitive way to determine when the PSA is higher than what can be attributed to an enlarged prostate. The net effect, however, is the same. Instead of dividing PSA into the gland volume, they do the opposite.  They divide the gland volume into the PSA. Using this inverted formula, an abnormal PSA relative to a specific-sized prostate is anything above 0.15.  Men above 0.15, using this formula, are said to have a high “PSA Density.”

 

A Suggested PSA Screening Protocol

It’s reasonable to start checking PSA yearly in men over the age of 45. Men with a family history of prostate cancer or men who are African-American should start annual testing at age 40.  Men over age 75 who are in good health should continue screening.

 

Using PSA to Stage Prostate Cancer

Despite the controversies that surround the use of PSA for screening, there are no controversies about using PSA for cancer staging. Men with a higher PSA at the time of diagnosis, above 10 or 20 for example, are more likely to have cancer that has spread outside the gland. The exact methodology for determining a man’s Stage of Blue, using PSA in combination with other factors, is explained in Chapter 1. 

 

PSA to Monitor for Cancer Relapse After Surgery or Radiation

Cancer recurrence is signaled by a rising PSA. Normally after surgery, the PSA should drop to undetectable levels. Even a small rise in PSA is significant. After radiation, the PSA should generally remain under 1.0, though exceptions certainly exist. The rate of PSA doubling is a very important indicator of the recurrent cancer’s aggressiveness. For example, recurrences associated with PSA levels that require over 12 months to double are low-grade. On the other hand, PSA that doubles in less than three months signals aggressive disease.

 

Determining the Response to Hormone Therapy or Chemotherapy

A PSA decline of more than 30 percent within a couple of months of starting chemotherapy provides a strong indication that the treatment is working. However, not every treatment, even when it is effective, makes an impact on PSA. Two new therapies for Royal—Xofigo and Provenge—clearly prolong life but may show little or no impact on PSA.

 

Conclusion

PSA results must be interpreted in the context of each patient’s overall circumstances by an expert with experience in managing prostate cancer. Unexpected PSA results should always be retested. Laboratory errors are possible and variations also occur between labs. 


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Stanley Brosman, MD is board-certified in Uurology.  Former Cchief of Uurology at UCLA/Harbor General Hospital, a Cclinical Pprofessor of Ssurgery/Uurology at UCLA,. and Aassociate Ddirector of Uurologic Ooncology at John Wayne Cancer Institute. He is past president of the urology section of the California Medical Society and . Ppast president of the Los Angeles Urologic Society. He is author or coauthor of more than 80 peer-reviewed scientific articles and over 50 book chapters or monographs. He practices urology with a focus on prostate cancer in Santa Monica, California, at the Pacific

 

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Interpreting the Pathology Report and Gleason Score


By Jonathan Epstein

Interpreting the Pathology Report and Gleason Score


By Jonathan Epstein

The two major components of the pathology report from a random 12-core biopsy are the Gleason score, which measures how aggressive the tumor appears, and the quantity of cancer in the 12-core specimen.

 

What Is The “Gleason Grade” Or “Gleason Score”?

The Gleason grading system assigns a “pattern” to the cancer cells, depending upon their appearance under the microscope. The patterns are graded from 1 to 5. The pathologist assigns a higher number when the appearance of the cancer cells deviates more from the visual appearance of normal prostate gland tissue. The first number in the score is the grade that applies to the most common type of cancer seen in the biopsy. The second number in the score is the next most common grade. These two different grades are then added together to yield the Gleason score. In actual practice, the Gleason score only ranges between 6 and 10.  Therefore, a Gleason 6 is the lowest, most favorable grade possible.

 

What Does It Mean to Have a Gleason Score of 7?

A Gleason score of 7 can mean 3+4=7 or 4+3=7, depending on whether grade 3 pattern or grade 4 pattern is predominant. The biggest therapeutic difference between these grades is that more aggressive radiation therapy protocols are often recommended for Gleason scores of 4+3=7 and higher.

 

What Does It Mean to Have Gleason Scores of 8 to 10?

Gleason score 8 cancers are aggressive, and Gleason score 9 to 10 cancers are more so. However, some patients with Gleason scores 9 or 10 can still be cured. The actual outlook for a specific patient also depends on additional factors, such as PSA, clinical stage, and the extent of cancer on biopsy.

 

Can the Biopsy Gleason Score Determine the Grade in the Entire Prostate?

The Gleason score on biopsy usually reflects the cancer’s true grade. However, in about 25 percent of cases the biopsy underestimates the true grade, resulting in under grading. Somewhat less commonly, over-grading occurs. This occurs when the true grade of the tumor is lower than that which is seen in the biopsy.

 

How Can Patients Be Sure the Reported Gleason Grade Is Accurate?

Assigning the correct Gleason score is developed through experience and practice. It is often prudent to submit the biopsy material for a second opinion to a center managing large numbers of patients with prostate cancer, to confirm the accuracy of the initial Gleason score.

 

Concluding Thoughts

A few years ago, there was a news story about a polar bear attacking a man in Canada.  Shockingly, the report said that the bystanders did nothing to help the poor man. However, upon further review it turned out that the reporter had neglected to report that the bear was only a cub, whose reach was lower than the man's knees. When facing a monstrous behemoth like cancer, the most important question to ask is "What kind of cancer am I dealing with?" 


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Jonathan Epstein, MD received his doctorateMD degree from Boston University. He completed Following his residency in anatomic pathology at The Johns Hopkins Hospital in Baltimore, Maryland, and a fellowship in oncologic pathology at Memorial Sloan Kettering Cancer Center in New York., hHe then joined the staff at The Johns Hopkins Hospital asand has been there his entire career. At the Johns Hopkins Medical Institutions, he is Professor of Pathology, Urology, and Oncology; the recipient of the Reinhard Chair of Urological Pathology; and Director of Surgical Pathology. He is the past Ppresident of the International Society of Urological Pathology. Dr. Epstein has 744 publications in the peer-reviewed literature and has authored 50 book chapters with a H-factor of 118. His most-frequently cited first or last authored publications is ‘‘Pathological and Clinical Findings to Predict Tumor Extent of Nonpalpable (stage T1c) Prostate Cancer,’’ published in JAMA, which establisheds the criteria for active surveillance. 

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Prostate MRI and Targeted Biopsy


By Daniel Margolis, MD

Prostate MRI and Targeted Biopsy


By Daniel Margolis, MD

Multiparametric MRI (MP-MRI) provides a three-dimensional image of the prostate, giving important information about the cancer’s location, size, and how “aggressive” it appears. MP-MRI also greatly increases the confidence that higher-grade cancers are not being overlooked in men on active surveillance. MP-MRI is usually performed without an endorectal coil.

 

“Multiparametric” Means Four Scans in One

There are four different imaging components to MP-MRI. The first is called “T2-weighted,” which creates the clearest images and gives the most capsular detail. The second and third parameters are called diffusion-weighted imaging (DWI) and the apparent-diffusion coefficient (ADC). These provide information about the aggressiveness of the tumor. The fourth, called dynamic-contrast enhancement (DCE), maps the blood flow of the tumor.

 

“PI-RADS”

PI-RADS (prostate imaging reporting and data systems) compiles a score composed of all four parameters—T2, DWI/ADC, and DCE—on a 1-to-5 scale. Lesions with a score of 4 or 5 are more likely to represent clinically significant prostate cancer (Gleason 4+3=7 or higher). Once MP-MRI detects a suspicious lesion, a targeted biopsy can be performed.

 

Evaluating Undiagnosed Men with High PSA Levels

There are notable advantages of MP-MRI over the random 12-core biopsy. First, it is less likely to diagnose clinically harmless cancers, sparing patients from unnecessary anxiety. Second, well-performed MP-MRI only misses significant cancer about 10 percent of the time, and these missed cancers tend to be small and unlikely to spread. To put this in perspective, a well-performed 12-core random biopsy misses high-grade cancer 25 percent of the time.

MRI for Active Surveillance

Until recently, men on active surveillance have only been monitored with periodic random 12-core random biopsies and PSA testing. MP-MRI provides three advantages over random biopsy. First, imaging is noninvasive. Second, imaging can find suspicious areas that might have been missed by previous random biopsies. Third, imaging provides a baseline measurement of the cancer’s size that can be used for follow-up monitoring to detect enlargement. As logical as imaging sounds, active surveillance strategies currently performed in most academic centers do not yet routinely use MP-MRI to detect cancer progression. Nevertheless, this concept is gaining traction.

 

The Future of Prostate MRI

The same imaging techniques for identifying prostate cancer for targeted biopsy can also be used to direct treatment. Focal therapy spares much of the surrounding normal prostate tissue from unnecessary damage. Given the increasing reliance on accurate imaging for state-of-the-art care, the importance of finding centers of excellence with skilled and experienced physicians will assume greater and greater importance.


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Daniel Margolis, MD earned his Bbachelor’s degree from Berkeley and his doctorateMD from USC, followed by an internship in internal medicine at West Los Angeles Veteran's Administration Hospital. He completed his residency in Diagnostic Radiology at UCLA, and a prestigious fellowship funded by the National Cancer Institute at Stanford. When he was in medical school, his former college roommate’s wife was diagnosed with breast cancer while she was pregnant with their third child. She succumbed to her disease within a few years, which had a pronounced effect on him. He chose to pursue a cancer-based fellowship, after which he stayed in private practice in the Bay Area. During that first year, a high school friend of his was diagnosed with pancreatic cancer, which sadly overtook her, too, again leaving behind a grieving widow and young children. Dr. Margolis decided then that being purely a diagnostic radiologist was not making the most use of his training, and took a job at UCLA where he could apply his skills to cancer research, achieving the most success with prostate imaging. He now serves as the Associate Professor of Radiology and Director of Prostate MRI at Weill Cornell in New York

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Color Doppler Ultrasound and Targeted Biopsy


By Duke Bahn, MD

Color Doppler Ultrasound and Targeted Biopsy


By Duke Bahn, MD

In Chapter 4, MP-MRI technology combined with a targeted biopsy was discussed.  This chapter will discuss an alternative type of imaging, called color Doppler ultrasound (CDU). Unfortunately, CDU followed by targeted biopsy is available in only a few centers around the United States. Even so, this chapter will expound the many advantages of CDU for the diagnosis and staging of prostate cancer.

 

Imaging with CDU utilizes two components; grey scale imaging and color Doppler evaluation of vascularity. With CDU, cancerous lesions appear as a dark spot. In addition, cancer can show increased blood vessel density, or “hypervascularity.” High-resolution CDU readily identifies tumors over 5 mm in diameter. Cancers that are visible on CDU are more likely to be clinically significant (Gleason 4+3=7 or above). Hypervascularity tends to indicate tumors with a higher grade. 

 

PSA, Gland Volume, and Diagnosis

Using an arbitrary PSA level as a trigger for doing a 12-core random biopsy casts such a broad net that over diagnosis becomes inevitable. Men’s prostates vary greatly in size—so the amount of PSA they produce varies greatly. Rather than recommending a 12-core random biopsy to every man with a slightly elevated PSA, my policy is to use a relatively low PSA threshold of 2.5 as an initial trigger to recommend a CDU evaluation. However, in men with risk factors such as family history or African-American descent, I use an even more conservative PSA cut point of 2.0 to recommend a CDU. In older men who tend to have larger prostate glands, a threshold of 4.0 is reasonable.

 

The first step should be to measure the size of the prostate with CDU. If a patient’s PSA is higher than expected for the individual’s prostate size, it increases the likelihood that an underlying high-grade prostate cancer may be present (Chapter 2 explains how to calculate a normal PSA level with allowance for the prostate’s size). Men whose PSA levels are in the normal range for their prostate size should not be subjected to invasive diagnostic procedures unless other suspicious findings are uncovered during the performance of the CDU.

 

Questions that Color Doppler Ultrasound Can Answer:

●      Where is the tumor located within the gland?

●      Does the tumor remain confined within the prostate?

●      What is the tumor’s diameter in millimeters? Does the size of the lesion detected by imaging coincide with the length of cancer reported in the targeted needle biopsy as reported by the pathologist?

●      Is tumor size or vascularity on sequential scanning increasing over time for men who are on active surveillance?

 

Final Thoughts on Prostate Imaging

Prostate imaging dramatically reduces the need for random biopsy. If an abnormality is detected by imaging, a targeted biopsy provides information that is of higher quality using far fewer stabs of the needle. Imaging should precede random needle biopsy. When a biopsy is required, it should be targeted rather than random. 


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Duke Bahn, MD is the Ddirector of the Prostate Institute of America. Certified by the American Board of Radiology, his special areas of interest are the early detection and staging of prostate cancer using color-Doppler ultrasound with tissue harmonics. He is also a pioneer in using cryotherapy, as both a primary and salvage treatment for prostate cancer. His published data was the impetus for obtaining Medicare approval for cryotherapy as a viable treatment for prostate cancer. Dr. Bahn has held many academic and professional appointments, including clinical professor of urology, Keck School of Medicine, University of Southern California. 

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Body Scans and Other Predictive Factors


By Fabio Almeida, MD

Body Scans and Other Predictive Factors


By Fabio Almeida, MD

While multiparametric MRI and color Doppler ultrasound are excellent tools for monitoring disease inside the prostate, scanning the rest of the body for cancer that may have spread to the lymph nodes or bones is also critical. Body scans are necessary for every Stage of Blue except Sky. Traditionally, doctors have relied on CT scans and bone scans. However, their accuracy is disappointing. Undetected spread is the most common reason for cancer recurrence after the initial treatment.

Positron emission tomography (PET) scans provide three-dimensional images of the whole body. The most recent and exciting discovery is that prostate cancer relies on fat as its energy source. Prostate tumors rapidly absorb fat when it is injected into the bloodstream, and if the fat is made radioactive by the insertion of radioactive carbon (C11), the tumors “light up” on a scanner. Lymph node metastases as small as 5-6 mm can be detected.

After lymph nodes, bone is the second most common site of metastatic spread. Standard bone scans use a radiotracer called Technetium-99, which is unfortunately not very specific. Other changes in the bone, such as arthritis or benign lesions, can be mistaken for cancer metastasis. A PET scan called NaF18 (radioactive sodium fluoride) provides superior specificity and sensitivity when compared with Technetium-99. NaF18 PET imaging used in combination with C11 acetate PET imaging in the same patient offers the most comprehensive method currently available for detecting cancer metastases.

C11 acetate PET scanning for prostate cancer is a giant leap forward over older scanning techniques, but the C11 scan center must be located immediately adjacent to a cyclotron facility and relatively few such centers exist. Therefore, new types of scans are being explored. Preliminary studies with Ga68 PSMA provide excellent images. Another promising new agent is FACBC (Axumin), which detects increased amino acid metabolism in the cancer cells similar to how C11 exploits increased lipid metabolism.  FACBC is now FDA approved and has recently become commercially available.

This wraps up the introductory section of the book. Armed with the results from your quiz in Chapter 1, which enables you to determine your Stage of Blue, it is now possible for you to jump ahead to the Chapter that addresses your Stage specifically:

 

                                                Sky:                Chapter 7  

                                                Teal:               Chapter 15

                                                Azure:            Chapter 25

                                                Indigo:           Chapter 30

                                                Royal:            Chapter 36


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Fabio Almeida, MD graduated top of his class and with honors from The Chicago Medical School. He completed a residency and fellowship in Nuclear Medicine at the University of San Francisco, and is certified by the American Board of Nuclear Medicine and the Certification Board of Nuclear Cardiology. He was in academic practice at the University of California, San Francisco, and private practice until 2005. Dr. Almeida is one of the pioneers in the development and implementation of cross modality fusion for cancer imaging (SPECT, PET, CT and MRI) and PET/CT. He also worked for the Centers for Disease Control after 9/11 for several years as a physician and informatics specialist consultant.

Indigo Overview


By Mark Scholz, MD

Indigo Overview


By Mark Scholz, MD

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Indigo Treatments & Side Effects


Indigo Treatments & Side Effects


 

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Indigo Subtypes


Indigo Subtypes


 

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Radiation for Indigo


By Christopher Rose, MD

Radiation for Indigo


By Christopher Rose, MD

Radiation is a mainstay for salvage treatment after surgery and a salvage option for relapse after previous radiation. Radiation, when it is given preventatively, while the PSA is still undetectable, is called adjuvant therapy. Adjuvant radiotherapy can be considered for men after surgery who have extracapsular extension, seminal vesicle invasion, or positive margins. In one prospective study, adjuvant radiation improved the cure rate from 41 percent to 61 percent. In another study, the 10-year survival rate was improved from 66 percent to 74 percent. 

Radiation delayed until PSA begins to rise is called salvage treatment. Salvage radiotherapy is given to patients whose PSA either fails to become undetectable after surgery, or if the PSA subsequently rises after being undetectable. Success rates are improved by using salvage radiation when the PSA is lower. The effectiveness of salvage radiation may be further improved with the addition of TIP in some patients.

What about Using TIP without Radiation?

In a study evaluating the 8-year cancer-specific survival rate with TIP alone, the rate with TIP alone was lower (86 percent) than what was achieved with the combination of TIP plus radiation (92 percent). In a different study, the results of a retrospective evaluation of 1,338 men with node metastases, the 10-year mortality rate was reduced by as much as 40 percent in the men who received radiation and TIP compared to TIP alone. 

Radiotherapy Side Effects

A good urinary outcome depends on delaying radiation until full urinary recovery has been achieved after surgery. Patients who are incontinent at the time of radiation usually will remain so. Regarding erectile function, delaying radiation as long as possible improves the odds of preserving it.  


Christopher Rose, MD is a board-certified radiation oncologist. He received his bachelor’s degree from the Massachusetts Institute of Technology and his doctorate from Harvard Medical School. His residency in radiation oncology was at the Harvard Joint Center for Radiation Therapy.  Dr. Rose was a visiting clinical scientist at the Institute for Cancer Research, Royal Marsden Hospital, University of London, in Great Britain.  He was an assistant professor of radiation oncology at Harvard Medical School. He also served as chairman of the Board of Directors and president of the American Society of Therapeutic Radiology and Oncology. He is past president of the Council of Affiliated Regional Radiation Oncology Societies of the American College of Radiology, past president of the California Radiation Oncology Society, and counselor of the American College of Radiology.  He is currently a member of the Medicare Coverage Advisory Commission and vice chair of the NCI-sponsored Quality Research in Radiation Oncology Study. Dr. Rose has published more than 50 peer-reviewed articles. He received the Donald Coffey Clinician Scientist Award from the PCF. He is the 2008 gold medalist of the American Society of Therapeutic Radiology and Oncology.

 

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Indigo - Cancer Relapse or Pelvic Node Disease


By Mark Scholz, MD

Indigo - Cancer Relapse or Pelvic Node Disease


By Mark Scholz, MD

Treatment for Indigo varies per the subtype. Men with Low-Indigo are presumed to have disease confined to the prostate or where the prostate used to be located.  Men with Basic-Indigo are at significant risk for micro metastases in the pelvic nodes. Unequivocal pelvic node metastases are associated with High-Indigo. 

Low-Indigo is defined by: 1) clear scans, 2) a PSA doubling time over 8 months, 3) the absence of any seminal vesicle invasion or extracapsular extension, 4) if the PSA is rising, it is less than 0.5 after surgery and less than 5.0 after radiation, and 5) the original Stage of Blue prior to initial treatment was Sky, Low-Teal or Basic-Teal. In men who relapse after surgery, the best chance for maintaining sexual function is to delay radiation or forgo it altogether. Men who relapse after radiation are typically treated with focal cryotherapy. Alternatively, they can consider salvage seed implantation or intermittent TIP. Men with doubling times over 12 months can consider observation alone without any immediate treatment. 

Basic-Indigo is defined as any one of the following, but without any proven disease in the pelvic nodes: 1) A PSA doubling time of less than 8 months, 2) Seminal vesicle invasion, 3) A rising PSA above 0.5 after surgery or above 5.0 after radiation, or 4) The original Stage of Blue was High-Teal or Azure. Men who had previous surgery are typically treated with IMRT to the prostate fossa and the pelvic lymph nodes along with TIP. Men who underwent previous radiation should receive TIP plus IMRT to the pelvic lymph nodes. Focal cryotherapy or salvage seeds are used for persistent disease in the prostate. 

High-Indigo is characterized by unequivocal pelvic node metastases and warrants multimodality therapy with long-term TIP (with Zytiga), IMRT to the nodes and Taxotere. 


Mark Scholz, MD is the executive director of the Prostate Cancer Research Institute. He is also the medical director of Prostate Oncology Specialists Inc. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is co-author of Invasion of the Prostate Snatchers.  He has authored over 20 scientific publications related to the treatment of prostate cancer.

 

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Unorthodox Therapies for Indigo


By Mark Scholz, MD

Unorthodox Therapies for Indigo


By Mark Scholz, MD

Some of the unorthodox treatments for Azure discussed in Chapter 28, such as aspirin, metformin, and statins, may be worthy of consideration for Indigo. Treatment with ancillary agents such as these should generally be considered as additions rather than substitutions to an overall protocol that includes standard anticancer therapies. 

Observation for Elderly Men with Low-Indigo or Basic-Indigo 

Normally, observation alone is reserved for men with PSA doubling times over 12 months. However, delaying therapy in older men with shorter doubling times can also be considered because the testosterone inactivating pharmaceuticals are very powerful and capable salvaging progressive disease and putting it in remission for years. Even milder form of TIP, using Casodex alone, can be considered. Casodex by itself has fewer side effects than Lupron-based TIP therapy.    

Taxotere for Basic-Indigo

A large, randomized clinical trial called STAMPEDE confirmed Taxotere improves survival for High-Indigo. There is also some limited evidence that Taxotere may improve cure rates for Basic-Indigo. In one prospective study of 60 patients, 25 percent of the men who began Taxotere, while the PSA was still less than 3.0, appear to have been cured using 4 cycles of Taxotere combined with 9 months of TIP. Patients often ask me what I mean by “cure.” After surgery, cure means that the PSA remains undetectable indefinitely in men whose testosterone levels have recovered back to normal levels. After radiation, cure means a recovered testosterone and PSA levels that remain stable under 1.0.


Mark Scholz, MD is the executive director of the Prostate Cancer Research Institute. He is also the medical director of Prostate Oncology Specialists Inc. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is co-author of Invasion of the Prostate Snatchers.  He has authored over 20 scientific publications related to the treatment of prostate cancer.

 

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Minimizing the Side Effects of Chemotherapy


By Richard Lam, MD

Minimizing the Side Effects of Chemotherapy


By Richard Lam, MD

The most common side effect from Taxotere or Jevtana is fatigue. If tiredness from Taxotere becomes excessive, changing the schedule of infusions to weekly may be less toxic. Also, the tiredness may be reduced by switching from Taxotere to Jevtana. Other side effects and methods to counteract them are briefly summarized here: 

Low Blood Counts

If the white blood count (WBC) drops below 500, the risk of blood infections sharply increases. Neulasta and Leukine increase the WBC. When a low red count occurs, called anemia, Aranesp or Procrit can build it back up. If these are ineffective, a transfusion may be necessary. Men with low platelet counts should stop aspirin and other anticoagulants. Bleeding should be treated with a platelet transfusion. 

Counteracting Fatigue

Exercise can make a significant difference (Chapter 45). Prednisone, Provigil, Nuvigil, caffeine, and ginseng (Chapter 46) may also improve energy levels. If fatigue is severe, the chemo dosage may need to be reduced or the time between infusions extended. 

Other Side Effects

Hair loss is reversible. Nausea is uncommon due to the modern anti-nausea medicines. Taxotere affects the taste buds, so keeping ice chips in the mouth during the infusion is advisable to reduce blood flow to the mouth. “Icing” of the fingertips during the infusion prevents fingernail weakening. Narrowing of the tear ducts can occur. Excess tearing may require an ophthalmology consultation to unblock the tear ducts. Another side effect of chemotherapy is neuropathy. Usually it slowly reverses after the Taxotere is stopped.


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Richard Lam, MD is aA board-certified internist and oncologist, and has been specializeding full time in the treatment of prostate cancer since 2001. He is director of clinical research at Prostate Oncology Specialists, Inc. Dr. Lam has written numerous articles based on his research. Dr. Lam received his undergraduate degree in biology, magna cum laude, at UCLA. He then went on to earn his medical degree at UCLA School of Medicine before completing his residency training in the specialty of internal medicine at UCLA Center of Health Sciences. He completed his oncology and hematology fellowship at Harbor-UCLA Medical Center.

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Situations Where PSA is Misleading


By Mark Scholz, MD

Situations Where PSA is Misleading


By Mark Scholz, MD

 

PSA is a powerful blood test for detecting a cancer relapse. However, there is always a danger of misinterpretation. 

PSA Rise after Surgery

A small chunk of benign gland is sometimes left behind after surgery. In such cases, PSA may hover indefinitely in the 0.1 to 0.3 range, even when no cancer is present. When evaluating a man with low levels of detectable PSA, the original Stage of Blue should be considered. If it was Sky, then benign prostate gland cells are a more likely explanation. In this scenario, PSA should be monitored to determine if there is an upward trend or not. Sequential scans to determine if a small nodule is present and growing may provide some additional information. PSA levels that don’t rise and nodules that don’t enlarge are more likely to be from persistent, noncancerous residual prostate tissue.

PSA Rise after Radiation

Noncancerous PSA elevations after radiation occur frequently, particularly after seeds. The “PSA bounce” is thought to result from radiation-induced inflammation of the prostate gland. A cancer relapse can be distinguished from a bounce by examining sequential PSA levels. A smooth upward progression is typical of a cancer relapse. With a bounce, levels tend to oscillate up and down in a zigzag pattern. Another factor to be considered is the original Stage of Blue because relapses after Azure are more common. Other factors that influence PSA levels after radiation and are the size of the prostate gland and the testosterone level. Clearly, interpreting PSA levels after radiation requires oversight by a physician experienced with the treatment of prostate cancer.

 

Now that patients with Indigo have finished this Section, they can skip ahead to Chapter 43 to complete the remainder of the book.


Mark Scholz, MD is the executive director of the Prostate Cancer Research Institute. He is also the medical director of Prostate Oncology Specialists Inc. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is co-author of Invasion of the Prostate Snatchers.  He has authored over 20 scientific publications related to the treatment of prostate cancer.