Microsoft word - page 1-us2-may 2009[2].doc

WRAMC Us TOO, Inc.
A PROSTATE CANCER SUPPORT GROUP
SPONSORED BY
WALTER REED ARMY MEDICAL CENTER
NEWSLETTER
VOLUME 18 NUMBER 2 MAY 2009

TO SCREEN OR NOT TO SCREEN, THAT IS THE QUESTION

Two recent major research studies stirred the pot again regarding the efficacy of routine screening for prostate cancer using the PSA test and the digital rectal examination. Fourteen prostate cancer organi-zations, including Us TOO International, responded by issuing this joint statement: A JOINT STATEMENT FROM AMERICA'S PROSTATE CANCER ADVOCACY, EDUCATION, AND
SUPPORT ORGANIZATIONS, WASHINGTON, DC, MARCH 23, 2009
Since 1993, when the PLCO trial was started, we have awaited the results of this trial with eager antici-
pation, as have others. The initial report of the results of this study -- and those of a comparable Euro-
pean trial -- published last week in the New England Journal of Medicine have told us two things:
(1) The studies offer conflicting evidence about the possibility of a prostate cancer-specific survival bene-
fit associated with the regular use of prostate specific antigen (PSA) testing and digital rectal examination
(DRE).
(2) These studies provide no convincing evidence that mass screening of men over 50 or 55 years of
age will lead to a prostate cancer-specific survival benefit within 10 years.
We have come together to make two clear statements about these trials:
(1) Above all we thank the patients, the investigators, and the national authorities that funded these two
trials for their efforts. The development and implementation of these trials over the past 16 years has
been an enormous commitment by all concerned.
(2) We enthusiastically support the continued follow-up of patients in the prostate cancer arm of the
PLCO study for at least a further 5 years, through 2014, as originally envisaged.
In addition, in the long-term interests of the health of every man in the USA, and with health reform rec-
ognized as a national priority, we wish to state the following:

Every man, regardless of his age, has the right to know whether he is at risk from prostate cancer, a
disease that still kills over 28,600 American men every year, and many more around the world. We en-
courage all men to be proactive, and to seek out information and support in regard to their health.

We shall continue to encourage every man to discuss his individual risk for prostate cancer with his
doctors, and to request the appropriate use of PSA and DRE tests until better options are available.
Further clinical action based on results of these tests is also a matter for serious discussion between
each patient and his physicians. (Continued on page 14)

INSIDE THIS ISSUE


PSA Screening . . . . . . . . . . . . Page 1 Panelists’ Comments . . . . . Page 8
Prostate-Specific Issues . . . . Page 3
Counselors Listing. . . . . . . . Page 15
WRAMC Us TOO

FROM THE EDITOR’S DESK

WRAMC Us TOO
NEWSLETTER EDITOR
The debate about prostate cancer screening continues. The ex- Write or Call
perts agree that there is no definitive evidence that early screen- Vincent P. McDonald
ing provides a prostate cancer-specific survival benefit. On the 8661 Chase Glen Circle
other hand, no one can dispute that early diagnosis of the dis- Fairfax Station, VA 22039
ease has led to a dramatic stage migration wherein men are be- Telephone: (703) 643-2658
ing diagnosed with earlier stage, treatable prostate cancer. The FAX: (703) 643-2658
crux of the matter is the ability of medical science to differentiate E-Mail: [email protected]
between indolent disease and aggressive disease, and thus pre- vent over-treatment with the attendant morbidities. Until then, we can expect the screening argument to continue. On another subject, we continue to seek ways to sustain the pub- MEDICAL ADVISORY STAFF
lication of the newsletter in the face of rising postal expense and a decline in support from the pharmaceutical industry. We hope Colonel David G. McLeod,
to make the decision soon for announcement in our August is- Jane Hudak, RN, PhD
Ginger Lew-Zampieri, PA-C

FEBRUARY SPEAKERS’ REMARKS

Kimberly Peay, RN, NP
Our February program featured a panel of men who described their experiences in dealing with prostate cancer. The program was well-received and there were enthusiastic exchanges be-tween the panelists and the audience. A summary of the panel BOARD OF DIRECTORS
Vincent P. McDonald
(President)
Raymond Walsh
MEETING SCHEDULE FOR MAY 6, 2009
(Vice President)
Edward T. Watling
So much is happening in medical science affecting prostate can- (Secretary)
cer, and Walter Reed’s Center for Prostate Disease (CPDR) is Philip Brach
right in the middle of it. Dr. Stephen Brassell, a urologic oncolo- (Treasurer)
gist at Walter Reed Army Medical Center and Assistant Director, Jack Barnes
CPDR, is well-qualified to bring us abreast of the latest promising Fred Blanchard
developments in the diagnosis and treatment of prostate cancer. Jim Padgett
His topic is “CPDR Present and Future – An Overview of Clinical George Savitske
Trials and Trends in Prostate Cancer Management.” Join us on Ken Simmons
Don Williford
Wednesday, May 6, 2009, at 7 PM in Joel Auditorium. Your fam-ily and guests are always welcome. DISCLAIMER: The materials contained in this newsletter are solely the individual opinions of
the authors. They do not represent the views of any Department of Defense agencies. This
newsletter is for informational purposes only, and should not be construed as providing health
care recommendations for the individual reader. Consult with your physician before adopting
any information contained herein for your personal health plan.
WRAMC Us TOO
PROSTATE - SPECIFIC ISSUES

WRAMC Involved in Phase III Clinical Trial
same side effects as other treatments, ac- for High Intensity Focused Ultrasound.
cording to researchers at Stanford University. Walter Reed Army Medical Center is the lat- est institution to be added to a number of Radiation therapy is an effective way to treat academic centers involved in a clinical trial localized prostate cancer. Proven successful that is investigating the safety and efficacy of treatments include brachytherapy and exter- High Intensity Focused Ultrasound (HIFU) using the Sonablate(R) 500 for the treatment involves small daily doses of radiation to the of locally recurrent prostate cancer following prostate, five days a week, for eight weeks to give enough radiation to kill the cancer cells (EBRT). Some men with prostate cancer who while sparing nearby healthy tissue. While are treated with radiation therapy have a re- effective, the duration of treatment can be turn of their cancer as determined by a rise in burdensome for some patients, particularly their Prostate Specific Antigen (PSA). Many those remote from a treatment facility. SBRT of these men have few alternatives other than gives a higher dose of radiation every day for The technology of using HIFU with the Son- In this study, King, et al., treated 41 men with ablate is a minimally invasive, outpatient pro- low-risk prostate cancer with SBRT. After a cedure that uses a transrectal probe to focus median follow-up of 33 months, no man in the ultrasound energy resulting in a therapeutic study has seen his cancer return. Men in the rise in heat within the prostate. This results in study reported side effects, including urinary the focal destruction of prostatic tissue. HIFU and rectal problems that were no better or does not use radiation and is non-surgical. In worse than with other prostate cancer radia- a small U.S. safety trial, 91 percent of the tion treatments. The researchers conclude participants treated in the study had a nega- that these early results are promising in the effort to reduce the duration of radiation treatment while possibly improving its effec- The principal investigators at Walter Reed tiveness. However, they note that it can often Army Medical Center in this study are: Ma- take as long as 10 years to see late side ef- jor(P) Steven R. Brassell, M.D., and Colonel fects and recurrences, so the men in the study will continue to be monitored closely. Eligible participants for the trial must be be- Further follow-up research will be necessary tween the ages of 40 and 80, and have bi- to establish that SBRT is as effective in the opsy- confirmed local recurrence two or more long term as other proven treatments for years following external beam radiation fail- early-stage prostate cancer. (Source: inter’l J ure. Other selection criteria are applicable for of Rad, Onc, Biol, Phy, March 15, 2009, via trial entry as well. Patients enrolled at Walter Reed Army Medical Center must be military beneficiaries. For more information about en- Alcohol is Great for Your Heart, But Not
So Good for Your Prostate! An interna-
http://www.prostatecancerrecurrenttrial.org/ tional team of scientists from Australia, Can- ada and the U.S. have concluded after a re- view of 35 studies that alcohol consumption may impact the risk of developing prostate Early Results for 5-Day Radiation Therapy.
Preliminary results show that a shortened drink 14 standard alcoholic drinks a week or course of radiation therapy for prostate can- more have a 20 percent greater chance of cer called stereotactic body radiation therapy developing prostate cancer than those who drink less. These findings clash with previous research indicating drinking two or more alco- WRAMC Us TOO
older than 75 years of age may not be equal holic drinks a day could prevent heart attacks. Further research is needed to determine both benefits and health risks related to alcohol This new study has not gone unchallenged. consumption and different types of disease. One observer comments that there are still Chikritzh, et al., Australia’s National Drug Re- many questions about whether PSA testing search Institute, say that men with a history of identifies clinically significant disease and prostate cancer or other indicators that would about how effective treatment is in older pa- tients. In fact, a recent update of the Scandi- should think seriously about keeping alcohol navian Prostate Cancer Group-4 trial showed to a minimum. (Source: ZERO, Vol. 5, No. 27, no benefit associated with radical prostatec- tomy for men older than 65 years. Another viewpoint says that for men who are 75 years PSA Predictive Ability for Black Men. Giri,
and older and others who have a life expec- et al., Fox Chase Cancer Center, Philadel- tancy of 10 or fewer years, the incremental phia, and the University of Chicago, studied benefit from treating their prostate cancer de- 646 men at high risk for prostate cancer. tected by screening is "small to none." Sixty-three per cent were African-American. (Source: J Urol. 2009; 181;1606-1614, via The PSA test had a higher predicted probabil- Medscape Medical News, February 20, 2009) ity of prostate cancer at values between 1.5 Urine Test May Identify Aggressive Pros-
tate Cancer. Researchers say their study
ample, at a PSA level of 3.0 ng/mL, the 3- indicates that an experimental urine test is "at year predicted probability for prostate cancer least as good" as the prostate-specific anti- gen (PSA) test for predicting which men have aggressive prostate cancer. Wei, et al., Uni- searchers said their analysis supported ag- versity of Michigan Medical School, Ann Ar- bor. The urine test, which assesses levels of American men based on higher predictions of prostate-cancer-specific metabolites, could prostate cancer. (Source: Cancer Prev Res eventually be added to PSA and other tools 2009:2:OF1-OF2 via Reuters Health Informa- for monitoring prostate cancer progression. However, the new study had a small sample, and the scientific approach to analyze me- PSA Screening in Men Over 75. New data
supports discontinuing screening for prostate needs further validation and development, cancer in men older than 75 years, but only in men who have low levels of prostate-specific antigen (PSA
3 ng/mL). Schaeffer, et al., The new study is the first time that "me- Johns Hopkins University School of Medicine, tabolomics," which surveys the metabolite Baltimore, say this group is unlikely to de- composition of cells and tissues, akin to the velop aggressive prostate cancer or to die of way genetics surveys their genetic composi- this disease during their remaining life. Not tion, has been shown to solve a real-world screening these older men would dramatically problem. The researchers believe that one of cut costs and would eliminate harm from ad- the metabolites, sarcosine, has the potential ditional evaluations and/or treatment in a to differentiate between benign prostate tis- population unlikely to experience benefit. sue and localized/metastatic prostate cancer. The Michigan researchers emphasized that their urine test is not a screening test and state that much more work has to be done before it can be used as a screening test. The study conclusions differ from earlier rec- (Source: Nature. 2009.457:910-915, 799-800, screening in all men who are 75 years or older. However, this study found that all men WRAMC Us TOO
Thalidomide for the Treatment of Bio-
diagnosis of cancer, to the point where other chemically Recurrent Prostate Cancer.
illness may have a substantial effect on their Thalidomide may help in the treatment of prostate cancer or a rise in their prostate- The mortality in these patients was similar to specific antigen (PSA) count after definitive that of men the same age without prostate primary therapy, according to a new study from the National Cancer Institute. The re- low- or moderate-grade tumors, mortality searchers point out that intermittent ADT is from prostate cancer was 2.1 percent versus increasingly being used in patients with bio- 6.4 percent from heart disease, and 3.8 per- chemical recurrence, and there might be a Treatment decisions for localized prostate cancer should consider life expectancy based dependent adenocarcinoma of the prostate on age and the contribution of other condi- and two consecutively increasing PSA counts tions to the patient's mortality, the research- after local definitive therapy with radical ers note. Also, the decision to use androgen prostatectomy, radiation therapy, or cryosur- deprivation therapy, which is now commonly gery. The use of thalidomide was associated used to treat even early-stage prostate can- with an increase in PSA progression-free sur- cer, must be made carefully if another signifi- vival after intermittent androgen-deprivation cant illness is present. Overall, the team con- therapy (ADT). However, the study's use of cludes that older men with early-stage pros- ADT in men with biochemical recurrence was tate cancer would be well served by an ongo- questioned by some observers. Larger stud- ing focus on screening and prevention of car- ies with longer follow-ups are needed to de- termine the usefulness of thalidomide in this (Source: Journal of the American Geriatric setting, note the study authors. (Source: J Society, January 2009, via Reuters Health, Urol. 2009;181:1104-1113, via Medscape More on Active Surveillance AKA Watchful
Prostate Cancer May Cause Neglect of
Waiting. Active surveillance appears to be
Other Illness. The majority of men with early-
safe for selected prostate cancer patients. stage, low- or moderate-grade prostate can- Guillonneau, et al., Memorial Sloan-Kettering cer die from causes other than prostate can- Cancer Center, New York, studied 268 men cer, according to a recent study. Therefore, younger than 75 years old who had multiple prevention and management of other health treatment options but ultimately chose active conditions is important in these patients. surveillance. The patients had a PSA level no Goodwin, et .al., University of Texas Medical higher than 10 ng/mL, clinical stage T1-T2a Branch, Galveston, assessed the outcome of disease, a Gleason score of 6 or lower, and 208,601 men between the ages of 65 and 84 no more than 3 positive cores at diagnostic years diagnosed with prostate cancer from biopsy. They had a restaging biopsy immedi- 1988 through 2002. Overall, 59.1 percent of ately before active surveillance began and no the entire group had early-stage prostate cancer with low- to moderate-grade tumors. Over a median follow-up of 29 months, 43 The researchers say that once a diagnosis of patients received treatment; 41 of them had cancer has been made, it often becomes the no disease progression at a median of 23 sole focus of medical care. This is under- months following treatment. At two years, the standable, because cancer is typically life probability of staying on active surveillance threatening and often requires aggressive was 91%. At 5 years, it was 75%. Patients therapy. But earlier cancer diagnoses, due to with cancer found on the second biopsy and screening, and improvements in treatment a higher total number of cancerous cores have been associated with lower cancer mor- were significantly more likely to undergo tality. Thus, patients are living longer after a treatment. Other factors, including age, PSA WRAMC Us TOO
and clinical stage, were not associated with women. While racial disparities are decreas- ing, the 2005 death rate for all cancers com- bined was 33 percent higher in black men According to the researchers, the study indi- and 16 percent higher in black women when cates that 75% of the patients who are real compared to that of white men and women, candidates for active surveillance will still ful- respectively. The report points out that the fill the same criteria 5 years later, demonstrat- causes of these disparities are complex and ing the absence of noticeable progression. likely reflect social and economic disparities, They also said that active surveillance, based not biologic differences. (Source: HealthDay on strict criteria and a repeat prostate biopsy might be a way to distinguish between pa- tients with a growing tumor that requires Dietary Fiber Intake and Prostate Cancer
treatment and those whose tumors will re- Risk. It has been suggested that dietary fiber
main indolent. These patients require con- may reduce prostate cancer risk, possibly by tinuing monitoring, but many of them will not increasing circulating levels of sex hormone- have disease progression and will not require binding globulin, which is inversely associ- any kind of active and treatment. (Source: J ated with risk. A recent European study says Urol 2009; 181:1635-1641 via Reuters Health that dietary fiber intake is not associated with Cancer Death Rates Decline Among
Allen, et al., University of Oxford, UK, used Blacks. Black Americans' cancer death
data collected from 142,590 men using vali- rates continue to decline, according to an dated dietary questionnaires. During an av- American Cancer Society report. However, erage follow-up period of 8.7 years, prostate they are still diagnosed at more advanced stages of cancer than whites, and blacks found no significant association between total have lower survival rates at each stage of dietary fiber intake and prostate cancer risk. diagnosis of most types of cancers. There will Calibrated fiber intake and fiber derived from be about 150,090 new cases of invasive can- fruit was associated with a small reduction in cer diagnosed in U.S. blacks in 2009 and risk for total prostate cancer and for localized about 63,360 cancer deaths. The most com- disease, but these associations were not sta- monly diagnosed cancers will be prostate (34 tistically significant, according to the re- percent), lung (16 percent), and colon and searchers. However, there was a statistically significant inverse association between cali- brated intake of fiber from fruits and late on- Cancer of the lung will be the most common set prostate cancer risk (cancer diagnosed at cause of cancer death in both black men (31 age 65 years and over). (Source: Int J Can- percent) and women (23 percent), followed cer 2009;124:245-249, via Reuters Health by prostate cancer in men (12 percent) and breast cancer in women (19 percent). Cancer of the colon/rectum and pancreatic cancer Now They Tell Me! Frequent masturbation
are expected to be the third and fourth most in young men is linked to higher risk of early prostate cancer, but it lowers prostate cancer risk for men in their 50s, according to a recent study. High levels of male sex hormones, or Death rates for all cancers combined have prostate cancer. But different studies have white men, mostly due to rapid declines in reached different conclusions. This team of lung and prostate cancer death rates among researchers at looked at whether men with black men. Overall, cancer death rates have more intense sex drives were at higher risk of also decreased among black women but at a prostate cancer. Dimitropoulou, et al., Uni- slower rate than among white women, likely versity of Nottingham, UK, obtained detailed due to smaller decreases in breast and colo- sexual histories from 840 men. About half the WRAMC Us TOO
at socioeconomic disadvantage by evaluating trends in prostate cancer severity in an ethni- cally diverse cohort of low income, uninsured The findings were interesting. Sexual inter- men served by a state-funded public health course did not affect prostate cancer risk. But frequent masturbation did--in different ways and at different times of life. The researchers The study involved a retrospective cohort study of 570 disadvantaged men enrolled in men's 20s and 30s increased their risk of the California program from 2001 through prostate cancer, but men in their 50s who 2006. It defined two measures of cancer se- masturbated frequently had decreased risk. verity: (1) the proportion of enrollees with For men in their 20s, "frequent masturbation" metastases at diagnosis, and (2) the propor- was two to seven times per week. Compared to same-age men who reported masturbating whose cancers had low, intermediate or high less than once per month, 20-something fre- quent masturbators had a 79% higher risk of Prostate specific antigen levels at diagnosis exceeded 10 ng/ml for 51% of enrollees, 50% For men in their 50s, "frequent masturbation" had a Gleason score 7 or greater and 43% was one or more times per week. Compared had clinical T-stage T2 or greater. Of disad- turbating, 50-something frequent masturba- at diagnosis and this proportion remained tors had a 70% lower risk of prostate cancer. stable over time. Among men with nonmetas- The study suggests that young men geneti- tatic cancers, 24% had tumors with low risk cally predisposed to have hormone-sensitive features and the proportion of low risk can- prostate cancer will be at higher risk if their bodies naturally produce high levels of male The study concluded that, unlike the broader them an intense sex drive. Masturbation itself United States population, the proportion of does not increase prostate cancer risk. More disadvantaged men with organ-confined, low frequent masturbation may just mean more risk prostate cancer has not been increasing. sex drive and more androgens bathing pros- It said that while much attention focuses on potential over-diagnosis and over-treatment of men with screen detected prostate cancer, On the other hand, the study suggest that in the findings suggest that for low income, un- older men, masturbation itself may actually be helpful, ridding the prostate gland of fluids that may contain cancer-causing substances. (Source: AWARE, Volume 5, No. 20, Janu- In maturity, it may be more important that tox- ins get flushed out of the system. The re- searchers hasten to add that these are just theories, and more research is needed to de-termine the exact role of sex hormones and sexual activity in prostate cancer risk at dif-ferent stages of life. (Source: BJU Interna-tional, January, 2009, via WebMD, January 27, 2009) Prostate Cancer Among Low Income, Un-
insured Men. The proportion of American
men with organ-confined, low-risk prostate cancer has increased significantly during the last two decades. Miller, et al., sought to de-termine if this positive trend extended to men WRAMC Us TOO
DEALING WITH PROSTATE CANCER – OUR STORIES
Five Prostate Cancer Survivors Relate their Personal Experiences
(A summary of a presentation to the WRAMC Us TOO Chapter on February 4, 2009)
RADIATION THERAPY AFTER SURGERY
Patrick Wesley
Introduction. My name is Patrick Wesley and I am a retiree from the Army Nurse Corps. This
is the first time that I have participated in a support group. I have always been proud to be a
health care provider but prostate cancer put me on the receiving end of the military health care
system. As I listened to the gentlemen on this panel I was impressed with the courage they ex-
hibited in telling their stories. My story isn’t quite as complex as theirs, but I think it will reinforce
the concepts that they have been sharing with us. As I prepared my remarks I reflected on the
fact that my wife Linda and I are both cancer survivors. Linda had her fight with cancer about 15
years ago and her experiences prepared us as a family to cope with prostate cancer. The
strength, fortitude, the positive attitudes and the humor displayed this evening will foster a posi-
tive attitude. So I think it is very important to hear these stories; it’s really important for me.
Getting Diagnosed. I had just turned 50 and I was practicing what I always preached about
preventative health care when I sought a check-up. During the digital rectal examination the
doctor uttered several “ahems.” Sure enough, a prostate biopsy was indicated. The results led
to a diagnosis of benign prostatic hyperplasia (BPH), and that was that, or so I thought! Then at
age 55, I experienced considerable foot pain that required surgery. As part of the pre-operative
procedure, I had some lab work done. My primary care doctor suggested that a PSA test might
be in order because the standards of care for African Americans my age encouraged the proce-
dure. It revealed that my PSA was “slightly elevated.” The foot surgery went off OK, and I pro-
ceeded to ignore the status of my PSA. My doctor persisted in her recommendation that I have
a follow-up PSA test., so I did. My PSA was even higher so another biopsy was performed. I
convinced myself it would replicate the earlier biopsy by confirming a diagnosis of BPH. I was
wrong—it was prostate cancer.
My wife and I were together at the time we got the news. It didn’t shock me as much as I
thought it would, probably because we had been through these processes in her case. I also
had the benefit of the patient education process at Walter Reed. It provided me with the infor-
mation and insights I needed to understand the available treatment options. After discussing
treatment alternatives with my urologist, I opted for the radical prostatectomy because, like
some of the other panelists tonight, I wanted the cancer out as quickly as possible.
Getting the Bad News. My recovery from the surgery was uneventful and my one-month fol-
low-up included a review of the post-operative pathology report. I had already obtained a copy
of the pathology report for filing a VA claim. Relying on my own medical training, I focused on
words like “small,” “moderate,” and “differentiated.” I even thought that the surgical margins
were negative. I interpreted all this to mean that “I’m out of the woods”, but that was probably
what I wanted to hear. I didn’t see the other words within the report indicating that the cancer
was beyond the prostate. We were so confident that I would recover from my surgery and con-
tinue with my life that my wife left town for a family reunion and I went to see my urologist alone.
WRAMC Us TOO
My urologist told me that I should have external beam radiation therapy to address the fact that
the cancer was outside the capsule. Consultation with the radiation clinic revealed that I would
not have the standard 25-day regimen. Rather, it would be more like 60 days! I joked that I had
a cousin who was arrested for armed robbery and he didn’t get that kind of time!
Dealing with Incontinence. At the time, I still had not recovered from my post-surgery inconti-
nence; I was using 8 to 10 pads a day. It wasn’t anticipated that the radiation therapy would
worsen my incontinence, but I began to use even more pads following radiation therapy. I was
getting very miserable about my reliance on pads, especially since I was back to work. I learned
that it would be about two months before follow-up PSA testing would provide information about
the success of the radiation therapy. The combination of the two-month wait and my worsened
incontinence made me apprehensive, so I sought help. I was started on medical management
for incontinence using the medication imipramine which is basically an antidepressant, but it has
a secondary use for treating enuresis. It took thirty days of the medication to get me to thera-
peutic level. My incontinence was worse at the end of the thirty days! I kept being reminded
that I had to give Mother Nature a year or so for the natural recovery of continence after a radi-
cal prostatectomy. So there was an initial reluctance to treat me further at that time. Fortu-
nately, I was able to convince the urologist to conduct a eurodynamic test to check the condi-
tion of my bladder and its capacity. The test led to the conclusion that my best alternative for
incontinence was the implantation of an artificial urinary sphincter (AUS). I have had an AUS for
about four months now and it is working very well after my body adjusted to it and I became
more adept at employing it. It has taken me from 8-10 pads a day to one and I am not sure if I
even need it.
Aftermath. So, how am I doing! Just fine, thank you! The post-radiation PSA tests say my
PSA is undetectable (less than 0.01). The AUS is getting the job done. Listening tonight to the
other panelists who have faced more difficult situations gives me confidence that should I have
recurrence there are therapies available to deal with it. I turned 60 yesterday and tomorrow my
brother Thomas undergoes a radical prostatectomy. As he faces uncertainty, we are closer
than ever. Now let me make an additional comment based on my own experience. I see three
aspects in dealing with a diagnosis of prostate cancer. The first is gaining an understanding of
the disease itself. Next is to become fully informed about the various therapies that may be
available to you—their likely outcomes and their potential side effects. And finally, engage your
support system (family, friends, support groups such as this one) by involving them, as appro-
priate, in every issue confronting you. I want to close by saying that I am doing very well thanks
to the military medical system, the superb medical staff that cared for me and the family and
friends who are my magnificent support system.
DEALING WITH RECURRENCE
Ray Walsh

Getting Diagnosed. Good evening, my name is Ray Walsh and I have been a cancer patient
for ten years. I prefer to refer to myself as a patient rather than as a survivor. I am not a survi-
vor, I am a lifetime patient. In 1997, I was a platelet donor at Walter Reed when a PSA screen-
ing was offered. It was September 1977 and my initial PSA was 1.8, but it rose to 7.3 by April
1999. A biopsy revealed a Gleason 7. I was 64 years old and I had prostate cancer.
WRAMC Us TOO
Selecting a Therapy. I had no other health problems worth mentioning at that time. I consid-
ered all the available therapies—surgery, external beam radiation, brachytherapy—but not for
long because I wanted the cancer out of my body. So I underwent a radical prostatectomy on
July 20, 1999. The bad news came with the arrival of the post-operative biopsy report. It re-
vealed a Gleason 9; the harvested lymph nodes were clear, and the margins were negative, but
cancer cells were found in my seminal vesicles and the cancer was aggressive. Recurrence
was likely.
Recurrence. Sure enough, about two years later in July 2001 my PSA rose. At that time,
Walter Reed was using a PSA of 0.4 as an indicator of recurrence after primary therapy. Now
we needed to confirm that the cancer indeed was back. The first action was a bone scan to de-
tect cancer spread; it was negative. Next we turned to the more sophisticated Prostascint that
looks at soft tissue. The Prostascint was positive--I had cancer cells running around in my body!
I was now graded as a T-3 with metastatic prostate cancer. We began considering treatment
alternatives because something had to be done. Salvage radiation was a likely option, but I was
apprehensive about it because in the meantime I had developed certain intestinal problems. I
feared that salvage radiation would only aggravate that condition. Instead, I started hormone
therapy immediately.
Hormonal Therapy. First choice was high dose Casodex (150 mg per day) which seemed ef-
fective, but it was having a detrimental effect on my liver functions so the Casodex was stopped.
A second bone scan revealed metastasis to the bones of my rib cage. In November 2002, I
started a regimen of two flutamide capsules daily and Zoladex injections every three months. I
also had the opportunity to participate in a clinical trial with the drug Zometa that was showing
promise in the treatment of breast cancer. Would it be effective in treating prostate cancer?
Men undergoing hormonal therapy are susceptible to osteoporosis because hormonal therapy
blocks the production of testosterone so essential to bone health. Even more important, there
was evidence that Zometa could retard metastasis of prostate cancer cells. It worked for me
because my subsequent bone scans were very favorable.
I took Zoladex by injection quarterly until July 2005 when a tiny titanium capsule, called Viadur,
was implanted in my arm. It feeds leuprolide acetate continually as part of the treatment for
hormone deprivation. Men on hormone therapy have regular PSA testing to monitor the effec-
tiveness of their medications. In my case, I was taken off flutamide because of rising PSA and
the low-dose Casodex again because of adverse liver impact. I am currently on a drug called
Ketoconazole together with hydrocortisone. Ketoconazole tends to affect your steroids, so the
hydrocortisone is prescribed to offset it. Like all medications, there are potential side effects,
such as nausea, weight gain, headaches, sleep disorder, and constipation. The Viadur implant
in my arm was replaced by product called Vartas because the manufacturer of Viadur stopped
production.
After I finished Zometa clinical trials the results were so good that it was decided to keep me on
Zometa. I have remained on Zometa for about seven years now, adjusted in accordance with
the judgment of my medical advisors. I have been on Ketoconazole for over 2 years now. My
testosterone was less than 2 at last measurement. This compares with a normal range of 280
to 800. Yes, my libido is affected to some degree, but I still appreciate feminine beauty, so I’m
not dead yet! Ketoconazole is not approved by the FDA for treatment of prostate cancer, so it’s
an off-label application. It is designed to treat fungus, but doctors noticed it had a decided bene-
fit in reducing testosterone. It is working for me.
WRAMC Us TOO
Aftermath. I am now at the point in my hormone deprivation therapy where the conventional
drugs have been employed. If my PSA begins to rise again, then chemotherapy is the remaining
option—an unwelcome alternative. Nevertheless, my PSA has been undetectable at less than
0.010 for over two years based on my current drug regimen. There are side effects from all of
them, but they are tolerable. Side effects include hot flashes, loss of energy, and breast ten-
derness and enlargement, for example. The side effects vary from person to person so I am
very happy with my current lifestyle, and if the PSA remains stable, then I’ll be OK.
In one respect, I have been able to deal with my prostate cancer over the years because I ob-
served cancer’s course in my daughter who valiantly battled breast cancer until it ultimately
claimed her after eleven years. During the course of her treatment, she taught me a few things
about how to live with cancer.
Finally, I should mention that incontinence after my radical prostatectomy has been persistent
from day one, even when I had a Foley catheter in place after surgery, and I drain to this day. I
eventually had an artificial urinary sphincter implanted, but it has not been without complica-
tions.
(In rely to a question about incontinence, Ray Walsh made these comments:)
The artificial urinary sphincter (AUS) changed my entire attitude about incontinence because I
felt I was largely back in control. It reduced my pad usage from 10-12 pads per day down to 1
or 2. The cuff of the AUS is surgically placed around the urethra at the bladder neck. Over time,
tightening and relaxing the cuff can lead to erosion or atrophy of the urethra. This may result in
a less than complete closing of the cuff resulting in some leakage. According to my surgeon, this
apparently is what is happening in my case because I find myself using more pads than in the
past. I try to compensate for this by controlled urination, i.e., I schedule myself to urinate every
hour or two.
VACCINE THERAPY FOR PROSTATE CANCER
Philip Brach
Introduction. The title of my presentation is “The Flip Side of Prostate Cancer” because I am
quite flippant about my disease. I think it helps to have a humorous approach to it. I will give
you a quick history of my initial treatment. It was the Wednesday after Labor Day in the year
2001. An 11-year old boy in a public school in Southeast Washington said, “You look sick.”
Asked how he could tell, he said, “I can see it in your eyes.” By the end of the week I had been
diagnosed with prostate cancer!
Vaccine Therapy. I had a PSA of 14.7 and a biopsy showed a Gleason score of 8. I didn’t
even know what a DRE was, but I soon found out! I had always thought it stood for “Director of
Religious Education!” After the biopsy I was sent directly to an oncologist because, as I subse-
quently learned, at that time a Gleason 8 indicated a 50-70 percent likelihood that the cancer
had escaped the prostate. No need to waste time with surgery and its attendant side effects. I
asked the oncologist, no pun intended, what is at the cutting edge in this business and he men-
tioned research efforts at the National Institutes of Health (NIH), and asked if I were interested in
participating. I certainly was because I hadn’t heard much that I liked about the conventional
therapies such as radiation or hormonal therapy that were available to me. So I hustled over to
WRAMC Us TOO
NIH and enrolled in a phase 2 clinical trial that sought to determine if vaccine therapy could re-
sult in a natural immunity to prostate cancer. The vaccine was designed to stimulate my im-
mune system to recognize and attack the cells making PSA. I received a monthly vaccine injec-
tion supplemented by self-injections at home. Since the clinical trial was an experimental pro-
tocol, I also was referred for conventional radiation therapy as a precaution. The original plan
was that I have both brachytherapy and external beam radiation, but eventually I had only three-
dimensional conformal radiation, mid way through the vaccine protocol. Upon completion of the
vaccine trial my PSA was undetectable and remained so until the summer of 2007. In retro-
spect, I am more than satisfied with the choice of the vaccine protocol that I made, even if the
results have not turned out as well as I had hoped.
Recurrence. In May 2007 my PSA started to creep up; by August it was doubling every two
weeks! So it was back to the NIH. Participation in other clinical trials was considered, but for
various technical reasons I was ineligible. Finally I was able to get involved in an effort to eradi-
cate a single metastatic lymph node. There is emerging evidence that if one or more metastases
that may still be curable, they are worth being managed aggressively. This involves what is
called stereotactic radiography, which is a high dose and relatively limited. Because mine was a
lymph node and these can spread in contiguity, my nodes above the previous field were also
treated to be sure. The tricky part is getting in enough doses to be able to eradicate the dis-
ease. In addition, I also began conventional hormonal therapy. A previous encounter with hor-
monal therapy was unpleasant, but this time I was determined to deal with it. At present I am on
a 3 month cycle of Lupron.
Where I Stand. My PSA is now down below 1.0, still detectable, but I am relatively happy
about it. Of course, there are some of the common side effects such as the bowel problems as-
sociated with radiation therapy. So as they say at American Express, I never leave home with-
out a pad and Imodium! I have been very happy with the treatment I have received. I am com-
forted by the possibility that my involvement with clinical trials at NIH may some day make a dif-
ference for other men. I encourage men dealing with prostate cancer to consider participation in
clinical trials that may be applicable to them. I am grateful to so many—the medical staffs that
have served me well, family and friends for their support, and the camaraderie and the support
of the men, such as you here tonight, who understand what others are going through. Together
we often joke about our predicament. Sometimes we may be honest and admit how badly we
feel, but when we do, we know that there is someone else who really understands us. Thank
you for listening. (Editor’s note. Subsequent to his panel presentation, Philip Brach again has
a rising PSA and is assessing his options. He says, “Keep tuned for updates and keep me in
your prayers.”)
DEALING WITH RECURRENCE
Thomas Bass

Getting Diagnosed. Good evening. I was diagnosed with prostate cancer in 1988, twenty-one
years ago at the age of 55. I am now 77. At the outset, my urologist said my PSA and Gleason
score were such that I could choose either a radical prostatecectomy or radiation. I chose sur-
gery because I wanted to get the cancer out just as you have heard from the other panelists to-
night. But during the operation the surgeon detected that the disease had spread to my lymph
nodes. So the operation was stopped, and after my recovery I underwent a 25-session regimen
WRAMC Us TOO
of radiation. Unfortunately, my PSA began to rise again after about three months. In those days, I suppose, orchiectomy (surgical removal of the testicles) was the primary therapy to eliminate testosterone from feeding the cancer. Nowadays, hormonal therapy would probably be the alternative. At any rate, I had the orchiectomy. At the time I didn’t know what an orchiec-tomy was, but I soon learned! But it didn’t solve the problem and after four months my PSA continued to rise. Flutamide, an antiandrogen, was the next attempt to control my PSA. It was effective for about a year, then the same story—a rising PSA. The next resort was to Casodex, another antiandro-gen, but after another year or so my PSA kept going in the same direction—up! So my prostate cancer had become hormone refractory. It was recommended that I enter a clinical trial, and I did so. It is a BNIT Vaccine Trial, an open label, dose-escalation vaccine trial for men with hor-mone refractory prostate cancer. Although my PSA is high at 24, it is holding steady and my doctors are pleased with that. In the meantime I have not experienced any side effects from be-ing involved in the clinical trial. In short, after 21 years with prostate cancer and having experi-enced the gamut of therapies to cope with a rising PSA, I am still hoping for the best. BLADDER CANCER AND PROSTATE CANCER
George Enders

Bladder Cancer. I live in a very unique place here in Washington, D.C., and all you gentlemen
are invited to come live there too. It’s called the Old Soldiers Home. And we are old, believe
me! I am old—I’m 84. But let’s forget about that. Well, I learned the hard way that I had blad-
der cancer. It was 2:00 am on May 22, 2006. I had to go to the bathroom and noticed that I
was passing blood, a lot of it. My condition was beyond the capability of the local dispensary, so
I was referred to the Urology Clinic at Walter Reed later that day. I told the lady at the desk
about my referral and asked to see a doctor. She said she could get me an appointment two
weeks hence! I said, “I’m sorry ma’am, but I’m urinating blood now, and I don’t know what I will
be urinating two weeks from now!” That did the trick. They rushed me to an examination room
and the doctor announced he was going to perform a cystoscopy to inspect my bladder. I didn’t
know what that was, but I soon found out! So he went up there, looked around, and sure
enough, there it was—a one centimeter cancerous tumor hanging down like a chandelier from
my bladder. The doctor was able to remove it then and there while I was still halfway conscious.
Fortunately, it had not invaded the muscle, so I still have my bladder. I’m told that many men
treated for bladder cancer end up wearing a bag for the rest of their lives, so I count my bless-
ings.
There was a ten-week follow-up routine. A solution would be placed in my bladder for about two
hours, and after urination, a specimen was collected for analysis. After two three-month inter-
vals, I went for a follow-up cystoscopy. They said “everything looks hunky-dory, come back in a
year.” So much for my bladder cancer!
Prostate Cancer. The year is up, and I’m back to the Urology Clinic as instructed. The doctor
said that there were indications that I should have a biopsy of my prostate and I did. After sev-
eral other procedures, I got the news. Guess what? I had prostate cancer and it had already
spread to my ribs and spine! That’s a big problem, isn’t it, ladies and gentlemen? I told myself,
WRAMC Us TOO
“Don’t worry about it. As soon as you start worrying about it, it is going to get the best of you.
Just do what needs to be done.”
Given my age and the fact that the cancer had already metastasized, my options were limited. I
was referred to the Center for Prostate Disease Research (CPDR) where a team of specialists
reviewed my situation for action. I began hormonal therapy, but after a while my system be-
came tolerant to the medications. Next, they suggested I enter a clinical trial and they explained
what was involved. After I agreed to participate, they again reviewed my situation to ensure that
the clinical trial was suitable for me. Some men resist participation in clinical trials, perhaps be-
cause there is no guarantee that it will help them personally. But that’s not how I felt. My par-
ticipation just might help me, but even more important, it may help other men deal with their
prostate cancer in the future. So that is why I enjoy being in this program, and besides, the
CPDR staff treats me like a prince! The clinical trial is a double-blind study, so I don’t know if I
am getting the medication or the placebo. Nevertheless, I feel better overall, so just maybe it’s
working for me. Each procedure takes about two hours. Blood is drawn, processed, and then
subsequently replaced back into my system. They have a beautiful selection of movies that I
watch throughout the procedure.
Ladies and gentlemen, I feel privileged to appear before you tonight. As you can tell by now, I’m
not all that big on the medical details like PSAs, Gleason scores, etc. Instead, I put my trust in
the medical staff here at Walter Reed. It’s been working for me. And, hey! I’m 84 years old!
Thank you very much for listening to me. (Editor’s note: George Enders is enrolled in the
Dendreon Phase 3 Clinical Trial at WRAMC. Dendreon (Provenge) stimulates the patient’s own
immune system, the body’s natural mechanism for fighting disease, to recognize and destroy
prostate cancer cells.)
____________________________________________________________________________
(Prostate Cancer Screening – continued from page 1)


We call upon the federal government to emphasize the need for more research into early detec-
tion technologies and methods that will lead to better and more accurate diagnosis of prostate can-
cer.

We call upon Congress to increase funding for the Prostate Cancer Research Program at the De-
partment of Defense. We call upon the National Institutes of Health to increase funding for prostate
cancer research through the National Cancer Institute.
• We call upon the medical research community to place greater emphasis on the development of
new clinical tests that can differentiate between those men at greatest need for aggressive pros-tate cancer treatment and those with indolent forms of the disease who can be well managed without invasive treatment.
This statement is approved by the following US-based prostate cancer advocacy, education,
and support organizations:

American Urological Association Foundation, Malecare Prostate Cancer Support, Men’s Health Net-
work, National Alliance of State Prostate Cancer Coalitions, Prostate Cancer Foundation, Prostate
Cancer International, Prostate Conditions Education Council, Prostate Health Education Network,
The Prostate Cancer Mission, The Prostate Net, Us TOO International Prostate Cancer Education
and Support Network, Virginia Prostate Cancer Coalition, Women Against Prostate Cancer,
ZERO – The Project to End Prostate Cancer
WRAMC Us TOO

WRAMC US TOO COUNSELORS

(As of May 1, 2009)
(THESE PERSONS ARE WILLING TO SHARE THEIR EXPERIENCES WITH YOU. FEEL FREE TO CALL THEM.)
SURGERY
Tom Assenmacher

PROSTATE CANCER AND SEXUAL FUNCTION
James Padgett

RADIATION
John Barnes

INCONTINENCE
Ray Walsh

HORMONAL
"Mac" Showers
WATCHFUL WAITING
Tom Baxter

CLINICAL TRIALS
Philip Brach

SPOUSE SUPPORT
Kay Gottesman
OTHER THERAPIES/MULTIPLE THERAPIES
Howard Bubel
(Cryosurgery, Hormonal, Sexual Function) (Cryosurgery, Hormonal, Intermittent Hormonal) (Surgery and Second Line Hormonal-Ketoconazole) WRAMC Us TOO

WRAMC Us TOO, Inc., NEWSLETTER
CPDR CLINICAL CENTER
WALTER REED ARMY MEDICAL CENTER
WASHINGTON, DC 20307-5001
______________________________
OFFICIAL BUSINESS
FIRST CLASS MAIL
FIRST CLASS MAIL

MEETING ANNOUNCEMENT

WEDNESDAY, MAY 6, 2009
JOEL AUDITORIUM (SECOND FLOOR)
MAIN HOSPITAL BUILDING, WRAMC

SPEAKER

MAJOR (P) STEPHEN BRASSELL, MC
Urologic Oncologist
Assistant Director, Center for Prostate Disease Research
Walter Reed Army Medical Center
An Overview of Clinical Trials and
Trends in Prostate Cancer Management
WRAMC Us TOO

Source: http://www.cpdr.org/patient-information/ustoo/0509.pdf