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Chat transcript: Correspondent Dan Rutz after prostate cancer conference

Dan Rutz

July 13, 1999
Web posted at: 1:27 p.m. EDT (1727 GMT)

(CNN) -- The following is an edited transcript of a chat with CNN Medical Correspondent Dan Rutz, who recently attended the 2nd International Consultation on Prostate Cancer in Paris, France. The chat took place on Friday, July 9, 1999.

Chat Moderator: Hi, Dan. Please tell us about the conference you just attended.

Dan Rutz: It's a pleasure to be here. The conference brought together experts on prostate cancer from around the world. There were presentations on new research in diagnosis and treatment and also some debate over screening for prostate cancer -- which, by the way, is the leading form of cancer found in men (excepting minor skin cancers) and the second leading cause of cancer-related death.

Chat Participant: At what age should one start being concerned about prostate cancer and begin getting checkups to make sure there is not a problem?

Dan Rutz: Most experts advise that men with so-called average risk should begin regular checkups for prostate cancer beginning at age 50. That means, around that age, during the routine physical examination, the doctor should examine the prostate gland by feeling it (through a gloved, lubricated finger placed in the rectum) and by offering a blood test called PSA. The physical exam looks for any lumps or hardness on the gland, and the PSA gives an idea of whether the gland is diseased. Men at higher risk, including African Americans, are advised to be checked earlier, possibly age 40 or 45.

Chat Participant: Are there any new developments in detection and treatment? I've heard horror stories about the process.

Dan Rutz: First of all, the detection sounds worse than it is. I have had these tests myself and can tell you that there is no pain involved. The test is done very quickly and really is over before you have time to respond. The problem is that none of the tests for prostate cancer are highly specific. That is to say, a PSA may be elevated and turn out not to be cancer. So it is possible that men will be unduly alarmed and subjected to more follow-up testing, which can be rather painful, and still end up not having cancer. In that case, they have gone through a lot of trouble for nothing. The problem, though, is one can't be sure until the tests are done; and untreated, prostate cancer can be deadly.

Chat Participant: Dan, what is a remarkable PSA score/reading?

Dan Rutz: PSA readings are recorded numerically. Anything around 1 or 2 is considered normal. In fact, most doctors don't become alarmed until readings go over 4. (And readings tend to run higher as men age). A PSA over 10 is highly suspicious for cancer and ordinarily involves follow-up testing, that is, a biopsy of the prostate gland for tissue samples, which can be examined under a microscope for cancer. That is the definitive diagnosis.

Chat Participant: How often should a man get this checked -- yearly? What about men younger than 50? Should they have routine prostate checkups?

Dan Rutz: Men of average risk are advised to be tested yearly beginning at age 50. If there is a family history of prostate cancer (father or grandfather for instance) or African American men, among whom the incidence of prostate cancer is higher, testing is suggested around 40 or 45. Most docs will do the digital rectal exam before age 50 but hold off on PSA until after that time unless the patient asks for it or is from a high-risk group.

Chat Participant: Does medical research support the use of saw palmetto for prevention?

Dan Rutz: I am not aware of saw palmetto being useful in preventing prostate cancer, but it is often used to prevent a benign prostate condition known as BPH. That is an enlargement of the gland, which causes some men annoying symptoms of having to urinate frequently and being unable to completely empty the bladder. Saw palmetto may slow down that process. It also can trigger a lower-than-normal PSA so should probably not be used during the several weeks leading up to the physical exam. (Ask your doctor about this if you are on saw palmetto).

Chat Participant: Dan, are there any dietary risks or lifestyle risks?

Dan Rutz: High-fat diets are associated with prostate cancer. So is smoking and sedentary lifestyle. Interestingly, there is strong evidence that the micronutrient selenium may protect against the disease. A heart-healthy diet, low in fat, high in basic nutrients, is possibly protective, though there is not a whole lot of evidence at the moment.

Chat Participant: What about brachytherapy? Is that the best treatment?

Dan Rutz: In Paris there was new information about brachytherapy. For those who don't know about it, the treatment involves placing tiny radioactive seeds (about the size of rice grains) into the prostate through a series of slender tubes inserted through the skin between the scrotum and rectum. These seeds then destroy the cancer and are left in permanently, as they gradually lose their radioactivity. The Paris data shows a 70 percent 11-year survival rate -- that is, men who had no evidence of cancer at that time. The advantage over surgery is a lower complication rate -- that is, less chance of incontinence or impotence. But surgeons argue that the best and surest treatment is surgical removal. Understand that in all cases where brachytherapy might be useful, the cancer is relatively early and is confined to the prostate. If it has already spread outside the gland, brachytherapy won't be enough to stop it.

Chat Participant: Is it safe to be around people after this procedure?

Dan Rutz: The amount of radiation extending outside the body is very slight. Some doctors recommend that grandchildren (or others) not sit on the man's lap during the first few weeks, and there may be some restrictions on sexual intercourse. But then again, few men would be interested in sex right after undergoing this procedure. The radiation does fade rather quickly (and) within a few weeks. I am not aware of any hazard -- real or theoretical -- regarding being close to someone with seed implants.

Chat Participant: My father just had radiation seed implants along with five weeks of external beam radiation. It has been a week, and he is experiencing some rectal pain. Is that normal?

Dan Rutz: I am not a physician, but I do know that radiation can be damaging to the rectum. I would suggest your father let the doctor know, as there may be some treatment to help him be more comfortable during this healing period.

Chat Participant: In Europe, is the thinking about dealing with prostate cancer wholly different?

Dan Rutz: That came up at the Paris conference. Many European experts are opposed to routine prostate cancer screening. They argue that it turns up too many false positives (that is, people who initially appear to have cancer but turn out not to.) They argue further that since prostate cancer is often very slow-growing, we may be inclined to overtreat it in the U.S. That is to say, by subjecting men -- especially elderly men -- to body-altering and unpleasant therapy, we may be doing more harm than good, since they are far more likely to die of something else first rather than of prostate cancer.

Chat Participant: Are they as likely to perform radical prostatectomy operations in Europe?

Dan Rutz: They are less likely to treat at all. But interestingly, a Paris surgeon is developing a laparoscopic procedure for prostate removal. This is "Band-Aid" surgery, and his results in over a hundred cases show there is far less pain and trouble for the patient, and the cancer control is just as effective as doing an open incision operation.

Chat Moderator: Earlier you said the conference covered new research in diagnosis and treatment. Can you tell us what is the latest?

Dan Rutz: First, regarding diagnosis: As I mentioned, the PSA is not very specific for prostate cancer, as it can go up for non-cancerous reasons. Researchers talked about a subset of PSA called PSMA (prostate specific membrane antigen) which may be more prostate-cancer-specific. They are experimenting with measuring this substance in semen, which could one day lead to far easier means of cancer detection. The PSMA may also be tied to cells from the immune system (dentretric cells) to form a "vaccine" for treating the disease. In one study involving around 50 patients from Washington state, a third responded to the vaccine. All of these men had very advanced disease, and standard treatments had failed them.

Chat Participant: Is there any data that shows the effectiveness of digital exams coupled with PSA testing?

Dan Rutz: I cannot recite numbers, but the data shows that both tests are more accurate than either one done alone. The digital exam only allows the doctor to feel roughly half the prostate (the side adjacent to the rectum). So, there could be a bump on the side that is inaccessible. The PSA could trigger a false negative (25 percent of men with prostate cancer have normal PSAs). So, the combined approach is favored.

Chat Moderator: Any news that came out of the conference that we haven't talked about yet?

Dan Rutz: One of the most interesting discussions was over the use of "artificial intelligence" computers for diagnosing and predicting cancer outcomes. The computer models are shown to be very effective in predicting the course of cancer and may be useful in helping doctors and patients decide on the right treatments. There is much excitement in this field right now.

Chat Participant: Are there any treatments for prostatitis?

Dan Rutz: Prostatitis is not cancer, as you know. It is an infection of the prostate, which usually affects younger men and may become chronic. Those who've had it say it is very painful and can adversely affect the quality of their lives. This conference did not deal with prostatitis, but ordinarily it is treated with long-term antibiotics. This is more likely to work if the actual cause of the infection can be determined. Sometimes this is not possible.

Chat Participant: When hormone treatment no longer keeps the PSA level down, what other effective options are there?

Dan Rutz: Hormone treatment is usually offered to older men or others whose cancer has spread beyond the margins of the prostate itself. It may involve drugs to counteract testosterone (which may make prostate cancer grow faster), or surgical removal of the testes is another option. Despite these drastic measures, the cancer may, and often does, continue to grow. There is not much, frankly, to offer these patients. Experimental treatments may help, including the vaccine I mentioned earlier. Also there is some research involving nutrients, such as selenium. I am aware of research at Columbia University in New York involving soy derivatives being offered to men with advanced prostate cancer. The data is preliminary but intriguing.

Chat Participant: Are there non-invasive diagnostic means (i.e., MRI or CAT scan) that can assist in diagnosing prostate cancer?

Dan Rutz: There is research into using these imaging techniques, but the gold standard remains the biopsy. This allows the pathologist to actually examine the cells under the microscope and rule cancer in or out directly. Other tests are less exact, even though they may not be invasive. Studies are underway to define new reliable markers for prostate cancer (such as PSMA, mentioned earlier), but they are not ready for prime time.

Chat Participant: What about a "new" PSA test -- I believe it's called "free PSA"?

Dan Rutz: This test is seen by many as an improvement over the basic PSA test in that in detecting "free PSA" as opposed to that which is bound to cells, the likelihood of cancer can be more accurately assessed. Free PSA is a good sign. The higher the percentage of it, the less likely there is cancer present.

Chat Participant: Is there any sort of increased risk for prostate cancer associated with previous occurrences of other types of cancer?

Dan Rutz: There is some research showing that people with a history of other cancers are more likely to develop unrelated tumors (new primaries, as doctors say) later in life. In addition, some cancer treatments increase the risk of new primary cancers. So the general rule is for those with any cancer history (other than minor skin cancers) to be followed more closely for life.

Chat Participant: What is the survival rate for prostate cancer? How much does it improve with early detection?

Dan Rutz: Early detection definitely makes a difference. If the cancer is confined to the gland itself at diagnosis, 70 to 90 percent of men are alive 10 years later. It depends, too, on the age of the man at diagnosis. Since this is primarily a disease of old age, men are likely to die of other causes before their slow-growing prostate cancers get them.

Chat Moderator: Any final questions for CNN Medical Correspondent Dan Rutz?

Chat Participant: Is Dan Rutz an M.D.?

Dan Rutz: I am not an M.D., but having covered this topic for years, and seen many of these treatments employed, I can tell you there is much to be encouraged about. It is, though, primarily up to individual men to take responsibility for their own health. That means taking the initiative in having physical examinations when we reach the appropriate age and not worrying about the process. These exams are not that big a deal, and the peace of mind afforded by a clean bill of health is to most people worth the time it takes to get checked over.

Chat Participant: What are you going to cover next, Dan? Any interesting topics coming up?

Dan Rutz: I am working on several stories. One of the most interesting to me is on nutrition -- specifically, the role of Omega-3 fatty acids in protecting people from clinical depression. This sounds wild, but there is great research from the National Institutes of Health showing benefit. Omega-3, by the way, is found in fish oil. Eat your salmon!!!

Chat Participant: Also, now they say tomatoes are good....

Dan Rutz: I've heard about the tomato connection, too. And canned is supposed to be better than fresh.

Chat Participant: Have any new Rx's been put before the people?

Dan Rutz: I assume you refer here to new treatments for prostate cancer. The newest prescriptions for early-stage disease are brachytherapy, which we've discussed, and cryotherapy, which we have not. That treatment involves freezing prostate tissue by way of probes inserted similar to the way brachytherapy seeds are placed (through the skin beneath the scrotum). This treatment seems to be effective, but there is not as much long-term data on it. Cryotherapy does also cause impotence most of the time because the nerves controlling erection are destroyed in the process. New forms of prostate removal surgery, by the way, often spare these nerves (at least on one side), so some patients can attain normal sexual function afterward. There is no guarantee, however. The primary advances at this point are to make early-stage treatments less traumatic. There is nothing big in chemotherapy for prostate cancer that I'm aware of.

Chat Participant: What are some of the early signs of potential prostate cancer?

Dan Rutz: The truth is for most men there simply are no early signs of prostate cancer. It can be there for a long time before anyone knows it. The presentation of small hard lumps on the gland (which only the doctor can detect) are obvious only during an examination. Most of the time there is no pain. However, if a man sees blood in the urine, this should be checked out. It is unlikely to be prostate cancer but could be some other cancer in the urinary system.

Chat Participant: How can we find out more about the information discussed today?

Chat Moderator: You can look here: www.urology-publications.com/urology8/index.htm

Chat Participant: Thank you, Mr. Rutz, for your excellent responses.

Chat Moderator: Please come back!

Dan Rutz: Thank you all for your participation.

Visit our chat calendar for a complete list of future events and past chat transcripts.



RELATED STORIES:
Chat transcript: Men's Health editor recaps annual survey
June 24, 1999
Selenium: New entry in fight against prostate cancer
June 17, 1999
The prostate prescription: Self-care alternatives for young and old
June 16, 1999
Doctors test less painful way to reduce enlarged prostates
May 17, 1999

RELATED SITES:
2nd International Consultation on Prostate Cancer
National Comprehensive Cancer Network
American Cancer Society
National Cancer Institute
Mayo Clinic Health Oasis: Vitamin E and prostate cancer
University of Michigan Prostate Cancer Program
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