Online Health Chat with Dr. Anthony Avallone
September 20, 2011
Cleveland_Clinic_Host: Prostate cancer is the most
common cancer in men, and the second leading cause of cancer deaths among men in
the United States. Every year, about 185,000 new cases of prostate cancer will
be diagnosed in the U.S.
Prostate cancer is a malignant tumor that usually
begins in the outer part of the prostate. In most men, the cancer grows very
slowly. In fact, many men with the disease will never know they had the
condition. Early prostate cancer is confined to the prostate gland itself, and
the majority of patients with this type of cancer can live for years with no
With so many treatment options available for prostate
cancer, it is easy to become overwhelmed with all of the information you’re
receiving from many different sources. We would like to give you the opportunity
to chat live with a prostate cancer specialist to have your questions answered
regarding signs, symptoms, diagnosis, testing, and treatment options.
Dr. Anthony Avallone joined the Cleveland Clinic staff
in 2009 and is part of the Glickman Urological & Kidney Institute. He
specializes in urologic oncology, adrenal cancer, bladder cancer, kidney cancer,
penile cancer, prostate cancer, testis cancer, and laparoscopic and robotic
surgery. Dr. Avallone sees patients at Cleveland Clinic’s Main Campus, Fairview
Hospital, and Westlake Family Health & Surgery Center.
Cleveland_Clinic_Host: If you would like to make an
appointment with Dr. Avallone or any of the urologists in the Glickman
Urological & Kidney Institute, please call 800.223.2273, ext.45600, or request
an appointment online by visiting www.clevelandclinic.org/appointments. Thank
Cleveland_Clinic_Host: Welcome to our Online Health
Chat with Dr. Anthony N. Avallone. We are thrilled to have him here today for
this chat. Let’s begin with some of your questions.
Screening and Assessment
zieglek2: What are the screening recommendations for
the average man? Who does them?
Dr__Anthony_Avallone: Screening for prostate cancer
remains controversial. However screened populations have a lower risk of death
from prostate cancer.
Screening is by the PSA (prostate specific antigen)
blood test. (It is used like mammograms in women. Early prostate cancer, like
early breast cancer in women, often has no associated symptoms.) It allows
earlier detection of prostate cancer. About 15 percent of newly diagnosed
prostate cancer patient are still found with a digital rectal examination (DRE)
and have a normal PSA, so DRE is done in conjunction with PSA testing.
The standard recommendation is for yearly PSA testing
to be done starting at age 50. African Americans and men with a first degree
relative with prostate cancer are at higher risk and, therefore, should be
screened starting at age 40.
ztestis: My PSA test result this past July was 1.0. I'm 52 years
old. Is this a safe level for someone my age?
Dr__Anthony_Avallone: There is no "normal" value for
PSA. However, this is in an acceptable range as long as your DRE is OK.
Looking at the PSA over time can be more predictive for prostate cancer than the absolute level, so I would recommend checking it
again in a year
wpresler_1: I am 53 and had a PSA of 4.6. Biopsy
showed cancer was removed with robot. What should be next step?
Dr__Anthony_Avallone: It depends upon the final
pathology report. If the final pathology report is OK, periodic PSA monitoring
is in order. The PSA should fall to zero and remain so after surgery. A
detectable PSA is usually a manifestation of recurrence.
pandora3: What would be the cause of a low free PSA
reading other than cancer?
Dr__Anthony_Avallone: Low free PSA can be an indicator
for prostate cancer, but is also seen in BPH (benign prostate hyperplasia).
pjhorvath: Is the PCA3 (prostate cancer gene 3) urine
test sufficiently accurate to decide if a biopsy is necessary? My number was
2.4, whereas my PSA at age 74 runs from 5 to 9. I have had prostatitis twice.
Dr__Anthony_Avallone: The most common current use for
PCA3 is determining the need to repeat a biopsy in a patient who has undergone
previous negative biopsy and has a persistently elevated PSA.
robm: I am 60 years old and my PSA went from 3.6 to
7.2 in one year. A second PSA showed 6.1. I have decided against further
treatment and am on Proscar® (finasteride) until November. At what
point do I need to take further action? How common is breast enlargement on
Proscar®? What are the risks if I decide to watch the numbers? At
what point should I take action?
Dr__Anthony_Avallone: If you are in good health, you
should talk to your physician about undergoing a prostate ultrasound and biopsy
to rule out prostate cancer, especially given the rate of change of your PSA.
Proscar® can cause breast enlargement
rarely and can be irreversible.
pjhorvath: How reliable is the PCA3 urine test
regarding the need to re-biopsy?
Dr__Anthony_Avallone: There is no test that is 100
percent reliable, but the PCA3 has added to our ability to counsel patients
regarding the risk of prostate cancer and the need to re-biopsy. It is more
specific than PSA.
Friedley: When a biopsy is done and 12 samples are
taken, what are the chances of missing the cancer completely or by chance
getting a more concentrated grouping of samples so it appears the cancer is more
Dr__Anthony_Avallone: The extended biopsy pattern that
you are referring to has a lower chance of missing clinically significant
prostate cancer than the sextant (six biopsies) pattern that we used years ago.
Nevertheless, no test is 100 percent accurate, so periodic PSA monitoring and
PCA3 evaluations are performed and, when necessary, repeat biopsies, as some
cancers are missed on the first set of biopsies.
gs4143ds: I'm on Lupron (leuprolide). Could Avodart®
(dutasteride) and finasteride have fewer side effects?
Dr__Anthony_Avallone: Lupron is hormonal therapy used
for treatment of prostate cancer. Avodart® and finasteride are
medications used for lower urinary tract symptoms due to BPH (benign prostatic
hyperplasia), which is a benign enlargement of the prostate all men develop (but
only some of which develop symptoms that require treatment).
nancyh: After radiation and hormone suppression, what
is best way to follow patients for recurrence or metastatic disease?
Dr__Anthony_Avallone: The PSA test is used for two
purposes. One is for screening and the other is for tumor surveillance. Although
screening remains controversial, there is no controversy in employing PSA in
tumor surveillance, which means monitoring the disease. It is a very accurate
test when used in this fashion and should be periodically checked after
radiation and hormone treatment, or any definitive form of treatment.
robtoby: I had a laparoscopic radical prostatectomy
nine months ago. I've already had one subsequent PSA test that was undetectable.
Going forward, besides regular PSA tests, are there any other tests (blood or
otherwise) I need to have?
Dr__Anthony_Avallone: PSA testing should be adequate
as long as it remains undetectable.
zieglek2: (From Twitter) If my PSA has gone from 0 to
.13 in 15 years, will it keep rising? This is after radical prostatectomy.
Dr__Anthony_Avallone: This is a very slow rise and is
usually followed and not actively treated. PSA doubling time over 12 months can
be managed conservatively in many patients, but should be discussed with your
Friedley: I was diagnosed with prostate cancer a year
ago. PSA 4.7, Gleason 6, Aureon 11. I have chosen active surveillance/watchful
waiting. I changed my diet and increased exercise. Since doing that, the results
of recent PSAs were: 12/13/10 4.2, 3/10/11 4.6 5/17/11 4.06 Free PSA 12/13/10 17
5/17/11 14. My question is: Is watchful waiting a reasonable approach for me;
and more importantly, how often should a repeat biopsy be performed? Thank you
Dr__Anthony_Avallone: Whether or not active
surveillance is reasonable depends upon your age and health, and what you are
most comfortable with. If you are reasonably healthy, you should undergo repeat
biopsies yearly, as PSA alone is not accurate enough for monitoring disease
progression or growth of the prostate cancer.
willrich: My prostate cancer was biopsied 4 1/2 years
ago with a Gleason Score of 7, PSA 10. My age is 86 1/2. I have opted for watch
and wait. I had several clean bone scans and, in the last six months, a clean
colonoscopy. The urologist reports no lumps or bumps, but a hard spot on the
left side. No symptoms other than fatigue. The latest PSA is 254. I am still
mentally alert and prefer to avoid hormonal therapy unless pain ensues. Do you
have any thoughts on my condition?
Dr__Anthony_Avallone: A PSA that high is usually
associated with disseminated disease. You should be followed carefully by your
urologist with respect to symptoms, and you will likely require another bone
scan if you PSA continues to rise. As long as you are feeling well and your bone
scan is negative, it seems reasonable to withhold hormonal therapy, but this is
a decision you and your physician should make.
WALTER: Which type of external beam radiation is the
most precise with the least side effects?
Dr__Anthony_Avallone: Over the last 20 years, we have
seen tremendous advances in radiation treatment for CAP (cancer of the
prostate). The newer forms of radiation allow the prostate to be targeted more
accurately, with reduced short-term and, hopefully, long-term side effects.
Any of the newer forms of radiation work well. As far
as I know, there are no head-to-head trials comparing the newer forms. It is
important to be treated at a center that does its own planning with an on-site
radiation physicist, such as we have at Cleveland Clinic.
engineer_no__121: I have clinical stage T2c prostate
cancer (PSA=9.7' cancer in both lobes, Gleason scores 2@8 & 3@7; percent of
tissue ranges from 5 percent to 30 percent). Is surgery or radiation the
recommended treatment and why? My priority is long-term, regardless of
short-term discomfort or inconvenience.
Dr__Anthony_Avallone: Radiation and surgery are both
good treatments for prostate cancer. Unfortunately, we do not know which is more
likely to cure clinically localized disease, which I presume you have. A
thorough discussion, taking into account your age and overall health and risk
preferences, should be undertaken with your urologist.
If you choose radiation, a discussion of hormonal
therapy before and for a period of time afterward should be undertaken, as it is
likely to increase your chance of cure in the presence of Gleason 8 disease.
Tstephan: I am 72 years old, in good health, RE shows
mod. enlarged prostate without discreet nodules, induration, or asymmetry,
annual PSA test since 1998 gradually rising from 1.6 to 10.1. in March 2011.
Prostate biopsy in June 2011 shows adeno-Ca in right lobe only, Gleason score
3+3=6 involving less than 25 percent of entire specimen. What treatment would
you recommend? If I choose active surveillance, when would you start with any
therapy? Are there yet any genetic markers to indicate slow versus rapid
progression of the tumor?
Dr__Anthony_Avallone: Low volume cancer with Gleason 6
pathology tends to have a good outcome with either radiation or surgery. Your
PSA puts you on the fence between low risk and intermediate risk disease,
though. Depending upon the size of your prostate and the number of cores
involved, cryoablation might also be a good treatment, but we do not have
long-term data as we do for surgery and radiation.
Depending upon the number of cores involved and the
PSA density, you might be a candidate for active surveillance. If so, you would
need to have another biopsy at one year, as PSA alone is not accurate enough to
determine whether or not the disease is progressing.
gks: Would you recommend IMRT (intensity-modulated
radiation therapy) following brachytherapy in a 65-year-old patient with a
Gleason score of 9?
Dr__Anthony_Avallone: Brachytherapy with an external
beam boost is sometimes utilized in high risk prostate cancer. This should be
discussed with a radiation oncologist, as there are plusses and minuses to this
approach just as with other forms of therapy.
Risks and Side Effects
tomgilbride: I was diagnosed with prostate cancer last
month. My Gleason score is 7. My biggest concern is the side effects of any
treatment that I will have. Can you comment on the side effects associated with
treatment, especially incontinence?
Dr__Anthony_Avallone: Radiation has a lower risk of
significant incontinence than does surgery, but it has other risks. The risk of
significant urinary incontinence after undergoing open or robotic prostatectomy
by an experienced surgeon is very low, less than 3 percent.
BigRog200: Over time, how do the various treatment
options compare related to: incontinence, impotence, and recurrence?
Dr__Anthony_Avallone: Unfortunately, this is a very
broad question and is related to the stage and grade of disease, body habitus,
and other medical conditions. You should have a frank discussion with a
urologist and a radiation oncologist to go over these questions.
robm: What are the possible adverse reactions to
prostate biopsy? I have been reading the Invasion of the Prostate Snatchers and
am concerned about any chance of incontinence. Before he passed away, my father
had incontinence in addition to dementia.
Dr__Anthony_Avallone: There should be no chance of
incontinence after biopsy. There is a very low chance of a serious infection. At
Cleveland Clinic, we have recently instituted a new policy for broader spectrum
antibiotic coverage before prostate biopsy to help minimize the risk of a
tomgilbride: What do you mean by complications in a
Dr__Anthony_Avallone: A regular radical prostatectomy,
whether done by an open approach or robotically, is associated with a low chance
of incontinence and a very low chance of rectal injury (requiring a temporary
colostomy in some patients). A post-radiation salvage prostatectomy is
associated with a very high chance of severe urinary incontinence and a chance
of rectal injury (which after radiation is often treated with a permanent
Revdwight: Five years ago in June, my prostate was
removed at Cleveland Clinic in Weston FL. This July, I was told that my PSA,
which had been undetectable for five years, had risen to 0.17. A month later, it
had risen to 0.18. My local urologist indicated that if it reaches 0.2, I will
need to consider radiation treatments. What do you think is going on?
Dr__Anthony_Avallone: A slowly rising PSA five years
after surgery is commonly associated with microscopic disease recurrence,
usually in the pelvis. You will need an evaluation with CT and bone scan, but
these are usually negative in this circumstance. Radiation can be associated
with a 60 percent cure rate in this setting.
donna: Hi. My father was diagnosed with prostate
cancer five years ago. It was contained in only two lobes, but with a Gleason
score of 8. He went through 42 radiation treatments. His PSAs have remained low
until this year. Now they have gone up to 19. The radiation oncologist has
started him on hormone therapy. His first PSA is now down to 0.3, so that is
good. My father is a good 86-year-old, very active and alert. Are we going in
the right direction with his treatments? I don't want him to be treated like he
is old. Although he knows he is, he does not act or look it. Do you have any
other recommendations? Thank you Donna
Dr__Anthony_Avallone: Your father has high risk
prostate cancer because of his high grade, and recurrence in this setting is not
uncommon. He should have had a bone scan and CT to evaluate him for metastatic
Hormonal therapy should be preceded by a bone density
evaluation. There are risks to hormonal therapy, including bone loss, hip
fracture, and cardiovascular disease. These risks should be weighed against the
status of his disease based upon staging studies. He should discuss the risks
and benefits of hormonal therapy in his case with his physician.
Tstephan: If there is recurrence of cancer after
initial IMRT, what can be done then?
Dr__Anthony_Avallone: I am assuming you are referring
to local recurrence. That is disease within the prostate, as opposed to
recurrence elsewhere in the body. There is no standard treatment for local
recurrence after definitive radiation therapy. Salvage radical prostatectomy is
occasionally utilized, but has a very high risk of complications.
Investigations using cryoablation are being done at
Cleveland Clinic by Dr. J. Stephan Jones and Dr. David Levy. Initial studies
show promise in treating local radiation failures with cryoablation.
Ray: I am 55 years old. I have adenocarcinoma, Gleason
grade 3+3=6 involving 1 core (10 percent 0. I am leaning toward surgery. I have
heard about a newer technique that eliminates the need for catheter after
surgery and provides for a higher level of normal functionality after surgery.
Is there a new technique or is this more of a marketing spin?
Dr__Anthony_Avallone: I am guessing that you are
referring to robotic prostatectomy with a suprapubic tube instead of a urethral
catheter post operatively, which some centers are doing. Unfortunately, there is
not enough data to say whether or not this will influence the chance of
developing scar tissue where the urethra and bladder neck are connected during
surgery after prostate removal.
Years ago, we would leave a catheter in place for
three weeks after prostate surgery. Nowadays, most patients have a catheter for
five to seven days post-op and seem to tolerate it well, whether they undergo
open or robotic surgery.
WALTER: When do you think HIFU (high intensity focused
ultrasound) will be approved by the FDA?
Dr__Anthony_Avallone: Unfortunately, there is no way
to know if or when it will be approved.
WALTER: Isn't the FDA doing clinical trials for HIFU
in cases of recurrence after initial IMRT?
Dr__Anthony_Avallone: I do not know if there are
clinical trials for HIFU for patients with radiation failure. At Cleveland
Clinic, Dr. Stephen Jones and Dr. David Levy utilize prostate cryoablation for
recurrence after radiation failure in selected patients.
While we currently don’t offer the treatment, because
it’s not FDA approved, we can talk with patients to see if it’s an option they
should consider. If they are interested in HIFU, they can see a Cleveland Clinic
physician and discuss it with them.
gks: What clinical trials would you recommend for
prostate cancer metastases to bone?
Dr__Anthony_Avallone: There are numerous clinical trials. Here is the link to ones at Cleveland Clinic:
You can also check the National Institutes of Health (NIH) Web site at www.clinicaltrials.gov.
Friedley: What effect have you seen in prostate health
of avid cyclists who spend a lot of time sitting on a bicycle seat?
Dr__Anthony_Avallone: I have not seen any effects, but
many cyclists now use seats with cutouts that prevent perineal pressure.
Cleveland_Clinic_Host: I'm sorry to say that our time
with Dr. Anthony N. Avallone is now over. Thank you again, Dr. Avallone, for
taking the time to answer our questions today about Prostate Cancer Treatment.
Dr__Anthony_Avallone: I enjoyed it! Thanks.
If you would like to make an appointment with Dr. Avallone or any of the urologists in the Glickman Urological & Kidney Institute, please call 800.223.2273, ext. 45600, or request an appointment online by visiting
www.clevelandclinic.org/appointments. Thank you!
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This chat occurred on 9/20/2011
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