Systemic? - an Opinion

Part I - In the beginning

  THINK ABOUT IT

  THE LUCK OF THE DRAW (BLOOD THAT IS)

  THE IMMUNE SYSTEM

Part II - Is this a war or just a holding action

   DR. FOLKMAN'S WAR

   IS RECURRENCE MORE AGGRESSIVE

Part III - A diagnosis - surely not

   IS THERE EVER A PROPER DIAGNOSIS

   WHERE ARE WE THEN

 FINAL SAY  

THINK ABOUT IT

Let me throw out something to think about.  "All prostate cancer is systemic following the biopsy or a treatment that violates in and around the capsule OR may be systemic even before this!"

This is something that has been in the back of my mind for a long time but I really have no answers nor is it proven anyplace in research to any great degree.  It is from my mind and what I have accumulated over 8 years of study of this disease - it is taken form bits and pieces of various things.  It does not reflect the current thinking of the majority of the medical community nor does it mean that this is my own thinking - just talking points if you will.

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THE LUCK OF THE DRAW (BLOOD THAT IS)

First a question:  Does the biopsy, surgery, brachytherapy, cryo spread the cancer cells?

I think we would all agree that the insertion of a needle or a knife could very well spread cells into the blood stream.  We have studies to show this is true - the studies also show that the cells disappear in a relative short time.  But is there a possibility that the disappearance of these cells in not they have died a normal death but they have anchored themselves to someplace in the body and kind of gone into a state of hibernation or non-activeness.  Again this is just my off the wall thinking - no evidence.  And, for example, there are those who think that this disease will always become systemic at some point in time (if you don't die first) despite any treatment and that we should be playing a "delaying game" rather than a "curing game.  My opinion is that we do have disease that is curable - but that may not preclude a new disease from appearing.  A 2nd prostate cancer if you will assuming that you still have a prostate or some part of it left.

Now remember that blood is going through the prostate gland 24/7 and in this process it could also be picking up tumor cells and spreading them throughout the body from the time of the first mutation to prostate cancer.  Is this different that the cells we set loose with a needle or knife.  I don't know and I don't know of anyone else that could answer this question - but it is part of the mix for consideration.

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THE IMMUNE SYSTEM

What about the Immune system - where does it fit into all of this.  That again is a 64,000 dollar question with conflicting views.  Some say that the immune system does not see our cells as abnormal cells and therefore the killer "T" cells do not attack them.  We have been trying for a number of years to find something that could attach to the tumor cells and make the "T" cells think they are invaders and attack and kill them.  So far not a lot of success along this line.  But here again the real scientific evidence is not strong either way.  It may be that the immune system will attack some developing prostate cancer or maybe only some cell types of prostate cancer - we simply really do not know.  A strong healthy immune system may keep the cancer away early-on but doubtful if there is any benefit in fighting the disease after diagnosis.  However one must remember that we will overall be better with a strong immune system and will give us a higher quality of life.

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DR. FOLKMAN'S WAR

There is some evidence that the prostate gland itself produces a chemical that inhibits the growth of cancer elsewhere.  (Book:  "Dr. Folkman's War")  However we have not really had any others who have verified this to any great extent and it is not commonly accepted as truly what is happening.  But remember those who do not believe in the theory may have monetary reasons to disagree.

I am bothered by the fact that this disease returns following treatments but seemingly more quickly and more often where the treatment resulted in a knife or needle being inserted in or around the gland itself.  This would include surgery, brachytherapy, cryo.  The question than becomes at what point would a tumor cell escape, how far would it travel, and when would it attach itself someplace else in the body.  It would seem that the more the blood is disturbed it might indicate that we would have a faster spread.  Thus surgery would have the higher and quicker rates of return of the disease.  However there would be many other things to bring into this equation such as inadequate brachytherapy or cryo to begin with, inadequate coverage of the gland, inexperienced doctors, etc., etc., etc.  Probably because of so many variables it is something that could never be proven.

Would this explain why mono brachytherapy (of any kind), mono surgery, mono cryo have what I would consider a somewhat less long term disease freedom (10 to 20 years using a 0.2 cutpoint)?  The addition of radiation immediately following the treatment (within a month - immediate for surgery) improves the chances because it kills the cells that may be within the field of radiation.  Would this be a reason why external radiation following other treatments might be more effective?  And so might hormonal ablation therapy be effective before and/or soon after treatment.

If the gland remains intact does it continue to produce the chemical (as per Folkman) that inhibits the spread of the cancer and therefore its removal the cancer is more likely to spread.  Is this spread more likely to be local or systemic.  And if it is local the radiation may but the kibosh on its growth and if it is systemic then HT (Hormonal Ablation Therapy) may put the kibosh on the androgen dependant prostate cancer cells (ADPC).  It may not have any effect on the AIPC (Androgen Independent Prostate Cancer) cells and they would continue their pattern of growth.  However in its destroying the ADPC cells it would thus keep these from mutating into the more dangerous AIPC cells.

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IS RECURRENCE MORE AGGRESSIVE

Sometimes we believe that if the disease returns following treatment it is a more aggressive disease.  To me it simply indicated that it is not a new disease - just a continuation of the original disease.  For example it is said that we may have prostate cancer for 6 to 13 years prior to the diagnosis.  Realize therefore that every man has had prostate cancer for years before it is found. 

Remember also there is various cell types with various levels of aggressiveness and various levels of response to treatment.  If the disease is systemic to begin with (or because of our limitations of diagnosis we don't fully understand the extent of the disease) the patient is treated with a treatment that simply does not kill all of the disease.  Part of it is left to grow.  If we knew the whole story about out disease we might of treated it with a more aggressive treatment.

We know that in round terms that everyone diagnosed with "localized" disease has a chance of 100% to be around 5 years out.  This drops to very small figures when you are diagnosed with advanced disease - that is disease that is outside the local area.  So we get diagnosed with localized disease but in fact unknown to us there is some spread of the disease that is beyond our ability to see.  So at year 6 of this disease you are diagnosed with "low grade" disease and you chose a treatment that may be adequate for "low grade" but unbeknown to you there is other cancer hiding someplace that continues to grow.

Now if this other cancer (not seen and not treated) is low grade it may take another 6 to 13 years of growth to show itself by a rising PSA.  If it is high grade cancer it will show itself relative soon that might be characterized by a rising PSA (however higher grade disease show less PSA).  In either of these cases it would appear that the cancer is more aggressive at the time that we call "recurrence".  Actually it would not be "recurrence" but a continuing growth of the original systemic cancer.

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IS THERE EVER A PROPER DIAGNOSIS

Lets look at this problem of diagnosis.  Perhaps the most important in being diagnosed is the Gleason score.  We have had a number of studies that have shown that it is frequently misread and most often misread at a lower grade.  We see too many times that when surgery is done and the gland is sliced and examined that the Gleason is often higher than it was at diagnosis.  Why is this?  Simply because the biopsy itself does not cover 100% of the gland it covers only a relative few needle sticks.  It does not seem to matter to the doctor if the gland is 20cc or 75cc - they still will do the standard biopsy which can be 6, 10 or 12 sticks.  Realize of course that in a 75cc gland the amount of gland biopsied is considerably less than a 25cc gland. 

Next one has to take into consideration that there are places in the gland that a normal biopsy can not cover and cancer does grow there.  These are always missed even with the most skilled doctors doing a biopsy.  There is a way to reach these areas and that is through the perineal area by sticking the needles through the area between the scrotum and the anus - but few Urologists are equipped to do this - and many are not even aware of the procedure.  Then some disease never shows itself until it becomes time to do a TURP and we find cancer.  Sometimes this is in men with a low PSA and already metastatic cancer may have developed.

In addition many of the pathologists who read sides on a local level do not know about or ever see what we call "variants" of prostate cancer.  These "variants" are always very aggressive and usually will kill the patient.

For the reasons above is why we advise everyone to get a reading by an acknowledged expert.  This is not just another doctor at the local level.  This is not just a doctor at a university.  This is not someone at a Lab reading slides.  It is a very few pathologists who really specialize in reading prostate cancer slides - and even they sometimes do not agree.  I don't care what your doctor tells you or what your Gleason is - you are risking your life if you do not seek an expert for a second opinion UNLESS you are going to treat your prostate cancer very aggressively.  For a listing of experts see Gleason Experts

The above does not take into considerations the idiosyncrasies of the PSA.  Only in a small percent of the cases does the PSA truly represent the tumor.  That is covered in detail at PSA and I won't go into detail here.

Then we have the staging - which is only as accurate as the doctor who does the DRE.  If you have five doctors doing a DRE - you would get five different opinions.  And then the doctor doing the DRE can only feel a small portion of the gland itself.

Simply put - diagnosis of prostate cancer can be and often is a mess.

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WHERE ARE WE THEN

Now if you understand the above you will know that the diagnosis is never absolute, actually I believe it is overwhelming inaccurate.  If it is inaccurate and you base your treatment on this diagnosis - you may be risking your life.  There are so many other things to consider in the diagnosis rather than Gleason, PSA and Stage (see Information Neded).  All together it makes for better information to make a treatment decision.

Is the disease systemic from the time we are diagnosed?  Is the disease systemic following any needles being inserted or surgery performed?  In either case we are dealing with a possibility of a systemic disease at the time of treatment - and we know little about the disease itself or how aggressive it might be.  Yet we take these inaccuracies of the diagnosis and base a treatment decision which may or may not be adequate.  However with a little more consideration we might choose a more aggressive form of treatment with a higher possibility of "getting it all" and living happily ever after - even if we do have to put up with some side effects at the beginning.

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FINAL SAY

Remember this is primarily rambling on my part, just something to think about, something that some may want to discuss.  There is little, if anything, written in stone with this disease so any discussion may be a learning tool and cause us to think a little.  But then some don't want to think about it, won't read it and will go along their merry way believing what they want to believe.  Others will ponder, digest, think about it, research and maybe see some light at the end of the tunnel.  But even if we do - it will take years before we see the sun.

And then again maybe all of the above is just a bunch of hooey that makes little sense in the long term - but we may never know.  Just remember you saw it here first <smile>.

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