So, we have a viewer whose prostate is enlarged and he has Gleason 6 prostate cancer. He's
been on dutasteride for about 6 months, but it's failing to slow his prostate growth,
and he wants to know what you think he should do next?
I have a lot of patients that are concerned when they discover that they have enlarged
prostates. Large prostates seem to be blamed for every kind of urinary inconvenience that
occurs, but oftentimes, it has nothing to do with the prostate's size. It has to do
with the bladder irritability as we get older or other factors. Sometimes, a large prostate
does cause some occlusion of urine flow, but a large prostate, per se, doesn't necessarily
indicate anything bad. In fact, there is some evidence that men with larger prostates who
have prostate cancer have better outcomes then men who have prostate cancer with small
prostates. So, I don't have anything against big prostates, and sometimes that idea that
gets into patients heads that they have to stop the growth of their prostate is, I think
unfounded. It's a — it's not necessarily a disease to have a big prostate, just like
it's not a disease to be tall or short or any other human characteristic. So, that being
said, sometimes enlarging prostates to occlude urine flow, and the Proscar, Finasteride,
Avodart, Dutasteride type medicines are popular medicines to try and slow that progression,
but the real goal is not to slow the enlargement of the prostate, it's to ensure good urine
flow, and there are other products on the market like Flomax, Uroxatral, Rapaflo that
relax the urinary passages and enable better urine flow. There's products that stop bladder
irritability like Mybetriq and Vesicare, and these sorts of medicines. So, the problem
just simplify into whether you have a big or a large or a small prostate. There's a
lot of other factors that translate into urinary problems, and people should focus on the urinary
problems, not on the size of their prostate.
So, we have a patient who is 69 years old, and over the last 10 years, his PSA started
at 1.2 and has gone up to 11 ten years later, and they've had an MRI with only Gleason 6
showing (they've had a biopsy and it was Gleason 6). They say their prostate size is about
the size of a 40-year-old, and that they've had the Prolaris DNA test which says they
have non-aggressive cancer. Because their PSA has gone from 1.2 to 11 over the past
10 years, they're wondering if there is anything they should do?
For a long time, PSA was the only indicator we had to determine if there was going to
be a problem with prostate cancer, and it's roughly useful still to this day. I tend to
think of PSA in increments of 10. So, low-risk is like from 1-10; intermediate-risk is from
10-20, and high-risk is 20 and above. Sometimes, when we share that with people, they realize
that these smaller changes don't have that much relevance, but in this case, the PSA
has jumped from one category to the other. They mention that their prostate is normal
sized for his age, and that would maybe be about a 40cc gland, and a PSA of 11 is a little
higher than you would expect. So, is the low-grade prostate cancer causing the PSA? It's not
an enlarged prostate that's causing it. Is it prostatitis? Some sort of low-grade inflammation.
That needs to be looked into. The process that they've used so far sounds reasonable,
and it sounds like they have looked into it. So, after thorough evaluation, if you don't
find a reason for the PSA to be elevated, we typically check the box and say it's probably
some inflammation or maybe the low-grade cancer, and we continue to watch the situation. It
has been fairly conclusively agreed upon by experts that PSA by itself is not a reason
to abandon active surveillance. The reason to abandon active surveillance is if you have
a biopsy and have proven change that it is no longer Gleason 6, that the grade has gone
higher. So, while it does create some consternation and concern and worry when PSAs go up, people
do need to look for the reason. We don't always find a perfect reason, but we don't use that
as a trigger to stop active surveillance. One of the backstops, I think, that's going
to be used more frequently in these people that have high PSA density that are under
surveillance is the PSMA PET scan, and that's another way to ensure and insure that very
thing we fear hasn't happened, that is, spread outside the prostate or that there's another
cancer somewhere else in the prostate as yet undiscovered. PSMA PET scans are good for
both finding new cancers in the prostate and, of course, making sure that there's nothing
outside the prostate.
So, for his particular case, how often would you suggest getting monitored? Like, of his
PSA getting checked or maybe imaging?
Yeah, we'd check the PSA 2 or 3 times a year in men that are on active surveillance and
we do color dopplers and MRIs once a year, and in the men that have high PSA densities,
some of those we've been getting PSMA PET scans.
What is the latest research on taking holidays from ADT, and when do you recommend they take
ADT again? So, what are the markers of restarting ADT when someone does take a holiday?
So, intermittent hormone therapy is a vast subject and it is well-established that it
is a safe proposition. We reserve intermittent hormone therapy for men that have been able
to get undetectable PSAs while on hormone therapy. So, people that go on hormone therapy
and can't get their PSA down to less than 0.1 or down to 0.05, in my opinion, are usually
not candidates for intermittent therapy, but those that do, usually a PSA end point is
utilized to restart treatment. If the PSA rises up to 2 or 1 or 5, or something in that
range. Some centers have said as high as 10 or 20 which seems a little bit high. I think
that this has now changed because of the PSMA PET scans are coming where in the past we
didn't have any way to find where the PSA was coming from. So, we just kept going off
and on hormone treatment over time, and now, with PSMA PET scans, we can detect where the
cancer is coming from when the PSA is less than 1, so I think the logical sequence going
forward is going to be to stop the hormone therapy and then as the PSA starts to rise
up to 0.5 or 1.0 get a PSMA PET scan and if there is a limited number of spots of cancer
visualized on the scan, then to usually administer radiation to eradicate them, and try and to
control the disease both with the hormone therapy plus targeted radiation.
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