Frank, 63 years old
Occupation: Retired accountant
Frank is retired and in good health. He keeps busy with leisure activities, sports, volunteer works, and his grandchildren. He has always been concerned with good nutrition and watches what he eats.
During a routine examination, his doctor detected a lump extending beyond the prostate and found his PSA level to be 23.0 ng/mL, five times higher than normal. A TRUS revealed a suspicious abnormality that appeared to extend beyond the capsule (envelope surrounding the prostate). Several biopsies were done in this area, and the pathologist determined that Frank has a grad 4+5 (score of 9) cancer. Frank underwent a lymphadenectomy of the pelvic nodes that showed the cancer had spread to his lymph nodes. The bone scan was normal.
What’s going on? Frank has fairly advanced prostate cancer that has spread to the pelvic lymph nodes (N1) but not yet to the bones (M0). It is now up to him and his doctor to choose the appropriate treatment. The chance of cure is low, but if Frank responds well to treatment he may live many years with a good quality of life.
Charles, 50 years old
Charles works 40 hours a week, plays golf, and jogs. During his last annual check-up, his doctor performed a digital rectal exam (DRE), and everything seemed normal. However, his PSA test results were a little high at 5.0 ng/mL.
The doctor carried out a transrectal ultrasound (TRUS), found no abnormalities, and collected some samples for biopsy. The pathologist determined that the prostate contained cancerous cells scoring 6 (grades 3 + 3) on the Gleason scale. Additional examinations came up negative.
What does it all mean? While the DRE and the TRUS showed nothing, Charles does have cancer, although it is not very advanced. After a radical prostatectomy, the pathological tissue analysis showed that the cancer remained within the prostate (T2) and had not yet spread to the pelvic lymph nodes (N0) or bones (M0).
Charles has a very good chance of being cured and will likely not require other treatment.
Louis, 64 years old
Occupation: Foreman in a paper-pulp mill
Louis’ prostate cancer scores 6 (3 + 3+) on the Gleason scale and his PSA tests 8 ng/mL. According to the Albertsen life tables analysis, there is a 68 percent risk that he will die within the next 15 years and a 23 percent chance that this will be due to prostate cancer; therefore, his chance of dying from other causes within this period is 45 percent. In other words, Louis is twice as likely to die of a cause other than prostate cancer sometime over the next 15 years.
The doctor suggests Louis opt for active surveillance instead of immediate treatment, with its possible side effects. Louis doesn’t agree, however; he cannot imagine living with the sword of Damocles hanging over his head and insists on treatment.
The doctor proposes surgery or radiation therapy, explaining the advantages and drawbacks of both. The doctor also uses the Kattan nomograms to calculate the risk of recurrence.
Larry, 67 years old
Occupation: Sales representative
Larry plans to retire next year, buy a sailboat, and travel the South Seas with his wife. Suddenly, his doctor informs him that he has localized prostate cancer, although it does not appear to be too aggressive.
The tumour is at stage T1 and scores 6 (grades 3 + 3) on the Gleason scale, and his PSA level is 5. The doctor presents the three treatment options—active surveillance, radical prostatectomy, and radiation therapy—explaining the benefits and drawbacks of each.
Larry is unsure. He takes his time to think about it, eventually deciding on active surveillance. Because it is likely that his cancer will progress slowly, he prefers to postpone treatment and enjoy his long-anticipated trip. He will see his doctor as soon as he gets back.
William, 71 years old
Occupation: Retired accountant
William is still alert and in good shape, with no known medical conditions other than localized prostate cancer that is at stage T2 and scores 7 (3 + 4) on the Gleason scale. William’s PSA level is 10.
Relating his family history, William mentions that his parents died at the ages of 98 and 99. The doctor determines that William probably has a similar life expectancy and presents the three treatment options—active surveillance, radical prostatectomy, and radiation therapy—explaining the benefits and drawbacks of each.
William opts for radical prostatectomy to maximize his chances of long-term recovery.
John, 67 years old
Occupation: Retired math teacher
John is 67 years old and divorced. The doctor informs him that he is suffering from prostate cancer with a stage T2 tumour scoring 6 (3 + 3) on the Gleason scale and PSA testing at 8 ng/mL. According to the Partin table analysis, there is a 44 percent chance the cancer has extended beyond the prostate, but only a 3 percent risk it has affected the seminal vesicles and a 2 percent chance it has spread to the pelvic nodes.
John is told that because the risk that the cancer has spread is quite high, he might need other treatments in addition to surgery. The doctor also informs him that the nodes will not be removed, since there is such a low risk that they are affected.
The Kattan nomograms are then used to calculate the risk of recurrence after five years, and John learns he has an 85 percent chance of being cured with surgery as his only treatment.
Eric, 73 years old
Occupation: Retired journalist
Eric has had a coronary bypass surgery. His cancer seems fairly aggressive at stage T2 and scoring 8 (grades 4 + 4) on the Gleason scale. His PSA level is 20. Eric wants a treatment that will help control his disease and give3 him hope for recovery.
Given his age and history of heart disease, he and his doctor choose radiation therapy rather than surgery. Adding hormone therapy to radiation for two or three years will help him control the disease better in the long term and increase his chances of survival.
Michael, 56 years old
Occupation: Mail carrier
Michael is in excellent shape. However, he recently discovered that he has relatively aggressive localized prostate cancer that is at stage T1 and scores 7 (grades 3 + 4) on the Gleason scale. His PSA level is 9.
Michael’s doctor suggests radical prostatectomy, adding that he may also need radiation therapy depending on what is discovered during the operation.
Paul doesn’t hesitate. He is about to become a grandfather for the first time, and he wants to see his grandchildren grow up. He is aware of the side effects and complications of treatment but reckons they are a small price to pay for being able to continue enjoying his family in the years to come.
Richard, 55 years old
Richard is married and works for a large company as an electrician. His cancer scores 8 (grades 4 + 4) on the Gleason scale. He has a stage T3 tumour and a PSA level of 15 ng/mL. Partin table analysis indicates there is only a 6 percent chance the cancer is still confined to the prostate and a 26 percent chance it has spread to the pelvic nodes.
Richard begins to think about radiation therapy. Before going any further, however, the doctor decides to perform a pelvic lymphadenectomy to analyze the nodes, since the chance they are affected is relatively high. The pathologist discovers metastasis has indeed occurred. According to the Kattan nomograms, there is an 85 percent risk the cancer will recur within the next five years.
Given the lymph nodes metastasis, radiation therapy or surgery alone are unlikely to cure the cancer. Richard and the doctor opt for hormone therapy in addition to radiation therapy to control the disease throughout the entire body.
Richard can increase his chances of survival significantly by beginning hormone therapy early, before bone metastasis takes place.
Robert, 67 years old
Occupation: Volunteer chauffeur
Robert was diagnosed with prostate cancer three years ago. At that time, the cancer had spread to his bones. He was prescribed an LH-RH analog (hormone therapy) and did well until a few months ago, with his PSA dropping from 150 at the time of diagnosis to 1. Six months ago, his PSA began to rise, and he developed intense pain in his hip and lower spine.
He received radiation therapy and zoledronic acid, and these relieved most of the pain in his hip. He then began chemotherapy with docetaxel (Taxotere) every three weeks at the outpatient oncology clinic. His PSA dropped from 50 to 2.5.
He felt much better and his pain disappeared completely. Apart from hair loss, he tolerated the chemotherapy quite well. It has now been three months since he finished his chemotherapy, and he complains of some recurrence of pain in his lower back. In addition, his PSA has gone up to 30. Otherwise, he is feeling very well.
His options were discussed with him. Since he is feeling healthy and had a good experience with previous chemotherapy, he has decided to begin cabazitaxel (Jevtana), to be administered every three weeks. He remains optimistic, continues to eat as well as possible, and stays active. He is well aware that a cure is not possible, but he is encouraged by the positive results reported with cabazitaxel. He knows that abiraterone is another option if needed in the future, as is MDV3100.
He is also aware that he could have access to new therapies by participating in ongoing clinical research. Given the new therapies available, he is optimistically looking forward to being present for his grandson’s birth in six months.