Online Health Chat with Anthony Avallone, MD, and Rahul Tendulkar, MD

Friday, September 30, 2016


Prostate cancer is the most common cancer in men in the United States. When diagnosed early, prostate cancer can be properly treated. There are many treatment options available including active surveillance, radiation therapy, brachytherapy and various surgical procedures. Join us for a free, private, online health chat about prostate cancer treatment options, and get all of your questions answered by Cleveland Clinic urologist, Anthony Avallone, MD, and radiation oncologist, Rahul Tendulkar, MD.

About the Speakers

Anthony Avallone, MD, earned his medical degree from University of California San Francisco School of Medicine. He completed his residency in surgery/urology at University of California San Francisco Medical Center followed by a fellowship in urologic oncology at University of Texas M.D. Anderson Cancer Center.

Rahul Tendulkar, MD, earned his medical degree from University of Michigan Medical School. He completed his residency training in radiation oncology at Cleveland Clinic and currently serves as the clinical director and residency program director for the Department of Radiation Oncology.

Let’s Chat About Prostate Cancer Treatment Options

Prostate Matters

dankrist: Is diet a factor at all with prostate cancer prevention and treatment?

Anthony_Avallone,_MD: Yes. In parts of the world that consume a plant-based diet with little or no saturated fats, prostate cancer is an uncommon disease. Men with advanced prostate cancer that change to that diet have improved outcomes when undergoing treatment and during follow-up.

browning7: What percentage of prostate cancer jumps into the bones?

Rahul_Tendulkar,_MD: A very small percentage overall; however, the risk of bone metastases increases with higher Gleason scores and/or higher PSA at the time of diagnosis.

MURupp: Are there any supplements that may be worthwhile in preventing or diminishing the risk of prostate cancer?

Anthony_Avallone,_MD: No, but reducing saturated fats and increasing the percentage of plant-based foods is helpful.

FlowerW: Does erectile dysfunction after prostate cancer treatment also mean no climax/orgasm?

Anthony_Avallone,_MD: No. Even if nerve-sparing surgery cannot be performed or is not successful, orgasm is preserved. However, if erections are lost from surgery or radiation, most patients can have erections restored with oral medicines, a vacuum erection device or injection therapy. A few may choose to undergo an implant.

Living with BPH

jercleclin: In November 2015, during my yearly urological exam, my urologist felt my prostate may be enlarging and could cause future urination problems. Is an enlarging prostate a possible sign of increasing chances for prostate cancer? What are the best procedures, if any, for reducing the size of the prostate?

Anthony_Avallone,_MD: Prostate enlargement, benign prostatic hyperplasia (BPH), is universal in men starting at about 40 years of age. It does not increase the chances of developing prostate cancer. BPH does not always need treatment, usually only if there are significant difficulties urinating. In the past, surgery was the mainstay of treating BPH; now, most patients are treated with medical therapy.

chickbull: I know I have BPH (since age 65), and I’m having more nighttime urinary wake-ups at age 82+. I take finasteride and tamsulosin, get no caffeine, and my blood tests are OK (have some low HGB at 12.5). Is it possible to have cancer not show in the blood test? I’m having a PVR next week.

Anthony_Avallone,_MD: It sounds like your main issue is incomplete response to medical therapy for BPH. If your PVR is significant, your doctor should consider evaluating you further with cystoscopy to look into the bladder and prostate. Although most patients can be managed with medicines now, some still require surgical treatment for BPH, especially if they develop chronic retention.

jercleclin: My doctor prescribed Alfuzosin, which is supposed to relax or smooth the muscles at the bottom of the bladder to enable more urine to pass through. After a couple of years, I’ve received no discernible relief. He then prescribed finasteride, which is supposed to help shrink the prostate. Again, no help. I now have retrograde ejaculation and my prostate has enlarged where my doctor said he was concerned urination may become difficult. I have two questions: Could finasteride actually cause the prostate to grow instead of shrinking it? Can retrograde ejaculation be reversed?

Anthony_Avallone,_MD: Finasteride should not cause the prostate to grow, but some growth might still occur while taking the medicine. Alfuzosin is more likely to cause retrograde ejaculation and this should reverse itself if the medicine is discontinued.

Decoding Test Results

crislic: Does an “apical positive margin of 1mm on radical prostatectomy for adenocarcinoma with a Gleason score 3 + 4 =7, tumor confined to the prostate, 0/13 lymph nodes involved, lymph-vascular invasion not identified” indicate further treatment such as radiation or a radiation consult is needed? I’m currently four weeks post-op and waiting for my first free PSA level in mid-October. I’m worried about a positive margin. Thank you.

Rahul_Tendulkar,_MD: A positive margin does increase the possibility of having residual prostate cancer, but not all patients with a positive margin will need radiation therapy. I prefer to assess the post-op PSA and the patient’s recovery from surgery before making any recommendations. There is great debate on exactly when radiation should be used; but typically in cases like yours, I would favor close observation and consideration of radiation if the PSA were to rise. We recently published the world’s largest paper on this topic of salvage radiation after a prostatectomy:

Rana04: I would like to know the best treatment option. My father did a prostate biopsy on January 11, 2016, and his diagnosis was “a minute focus of prostatic adenocarcinoma in the left mid zone, Gleason Grade 3+3=6/10, 1 out of 12 cores involved. An immunohistochemical analysis was performed on the minute atypical focus in the left mid zone. There is a lack of basal layer staining with HMWK and p63 while AMACR is positive consistent with a small focus of adenocarcinoma. PSA blood normal. Findings Transrectal ultrasound guided prostate biopsy completed on January 11 2016: Prior to biopsy the periprostatic soft tissue was infiltrated with 10 cc of 1% lidocaine. The estimated prostate size 39.2 mL No definite solid prostate abnormalities seen. The midline of the peripheral zone toward the apex there is an ill-defined hypoechoic 10 mm area, which has the appearance of a cyst on some of the images. This lesion could not be sampled as the prostatic urethra was in very close proximity to the finding.”

Anthony_Avallone,_MD: Unless your father is in his 40s, active surveillance, rather than definite treatment, would be reasonable. It’s true that Gleason 6 disease has a very low likelihood of spreading or leading to a person's death; however, if active surveillance is pursued, he should have another test – either restaging prostate biopsy or a prostate MRI – to confirm that only low volume Gleason 6 disease is present. On active surveillance protocols, this is usually done within the first six months of the initial biopsy. About one-third of patients on active surveillance will progress and need treatment. Fortunately, the very slow growth rate of low-grade prostate cancer cells allows us to do active surveillance and avoid treatment.

Specific Solutions

MURupp: Could you please discuss the pros and cons, and any other info, on the CyberKnife® Radiosurgery System for prostate cancer.

Rahul_Tendulkar,_MD: CyberKnife is a trademarked name for a type of linear accelerator that delivers x-ray on a robotic arm. It is commonly used for stereotactic body radiation therapy (SBRT), in which typically five high-dose treatments are given over one to two weeks. SBRT is a new advancement in radiation therapy, with results suggesting PSA control and toxicity outcomes that are comparable to conventional intensity-modulated radiation therapy (IMRT) over about eight weeks. Given the more convenient schedule and favorable outcomes, I predict that SBRT will probably become the preferred method of external radiation in the coming years. There are several delivery systems that can offer SBRT, with CyberKnife being one of them – just like there are different manufacturers of sports cars or SUV’s, for example. There is no evidence that any one machine or vendor is superior to another.

FlowerW: What is the difference between seed radiation and beam radiation? Which one does Cleveland Clinic call brachytherapy?

Rahul_Tendulkar,_MD: A “seed implant” is a form of brachytherapy in which radioactive seeds are placed directly into the prostate via long needles. External beam radiation involves x-rays generated by a machine (called a linear accelerator) that are directed at the prostate and pass through the surrounding tissues. For early stage prostate cancer, both are considered appropriate treatment options with slightly different side effect profiles – notably more urinary side effects with seed implants and rectal side effects with external beam.

Demon: Is it true that you will lose a half inch off your penis if you choose surgery? Is the new gene replacement therapy just as good as surgery?

Anthony_Avallone,_MD: A minor loss of penile length is common after radical prostatectomy, whether performed in an open or robotic fashion. It is partially dependent upon whether or not a nerve-sparing procedure is performed.

FlowerW: A biopsy shows prostate cancer only in one area of the prostate gland. In our case, “R base 3+4, R mid 4+3, R apex 3+4 & R central mid 3+3, and the PSA is 14.” Prostatectomy is chosen treatment. Should the surrounding enveloping area also be removed (because it may be leaving prostate)? If so, would the surgeon include the seminal vessel entirely or just damage to the seminal vessel?

Anthony_Avallone,_MD: You have high-risk prostate cancer, and the radical prostatectomy typically includes removal of both seminal vesicles. It should also include removal of both the right and left pelvic lymph nodes. You should discuss with your doctor the risks and benefits of whether or not nerve sparing should be performed.

skibum: Does Cleveland Clinic have statistics on which prostate cancer treatments have been the most successful? In other words, have robotic surgeries resulted in fewer complications and lower cases of incontinence than open surgeries?

Rahul_Tendulkar,_MD: At Cleveland Clinic, we have one of the world's largest databases collecting outcomes of prostate cancer treatments, and we internally review our outcomes every six months. In our experience, prostatectomy, external radiation, and seed implants have very similar tumor control outcomes for early stage prostate cancer (see our publication from a few years ago: A recent randomized trial of active surveillance vs. surgery vs. radiation. ( showed that 10-year survival rates were similar between the three arms. Patients who underwent surveillance had a higher rate of developing metastatic disease than those who had surgery or radiation. Patients who had surgery had higher rates of urinary incontinence and erectile dysfunction, while those undergoing radiation had higher rates of rectal bleeding.

Diagnosis and Follow-up

bickp: My PSA average over the past 15 years is .98. Over the last five years, it’s been in the 1.2 range. In November 2015, it was 10.53, which was very alarming. Two weeks later, it was 2.5, and three months later, it was 1.3. My doctor suggested I return to yearly checks with no explanation about the spike. 1.Do you have any ideas about the spike? 2. Do you agree that I should return to a one-year plan? Also, my prostate was enlarged, with ongoing symptoms of slow flow.

Anthony_Avallone,_MD: That sounds like a reasonable plan of follow up. Rapid changes in PSA, especially if the level comes down like yours has, are usually from prostatic inflammation. Any inflammation in the prostate can lead to marked elevation of PSA. Sometimes, prostatic inflammation can occur without symptoms. Without treatment, rising PSA levels that are due to prostate cancer do not fall on their own.

skibum: What is the optimal method to monitor the status of prostate cancer? PSA blood work is the most convenient and cost effective, but I’ve heard it’s not always accurate. Digital rectal exams aren’t exactly pleasant and may not be accurate either. Biopsies, especially fusion biopsies, are probably the most accurate but are invasive and costly. I’ve also heard that a biopsy is like “kicking a hornet’s nest.” Do you agree? I’ve just learned as the result of a recent MRI, my Cleveland Clinic urologist has recommended a fusion biopsy. I’ve done some research and think I understand the benefits of this over a standard biopsy, but I’d like to understand the procedure better and its advantages. How do urologists use the size of the prostate as reported by an MRI in their diagnosis? My understanding is 15cc-30cc is normal and mine is 33.8.

Rahul_Tendulkar,_MD: After curative treatment such as surgery or radiation, usually PSA is the best way to monitor the status of prostate cancer. In patients who are undergoing active surveillance, there is an emerging role for MRI in detecting clinically progressive prostate cancer. A biopsy is usually recommended at some point to determine whether a cancer under active surveillance has progressed to a more aggressive grade or stage – in which case a curative treatment approach may be recommended. Biopsies do have risks such as infection and bleeding, and so it is important to discuss the pros and cons with your urologist. A 30 cc prostate size is fairly typical; size usually only matters if you are considering brachytherapy, for example, with some guidelines suggesting it may be more difficult to perform a seed implant on very large glands (>60 cc).

emile: I have a 4K score indicating a one in five chance of developing aggressive prostate cancer. My biopsy came back clean, but should I have it again? When or how often?

Rahul_Tendulkar,_MD: This is an area of active exploration. Because the 4K score is a relatively new test, we are still learning how best to proceed with the information. Some suggest that an MRI may be useful to look for prostate cancer and direct biopsies toward them.

Hormones and Immunotherapy

afflicted2: With Provenge (sipuleucel-t), will hormone treatment (Lupron) continue to be necessary? In Provenge's warnings and precautions, it states "acute infusion reactions." Could you elaborate on that and how serious of a risk it is? Does the collection of cells in Provenge therapy jeopardize the immune system? What are the risks of cell collection? Is the only benefit from Provenge the possibility of longer life?

Rahul_Tendulkar,_MD: Provenge is a form of immune therapy used to treat men with metastatic prostate cancer, typically in asymptomatic men with castrate-resistant disease (i.e., it no longer is responding to typical hormone therapy). This treatment is typically administered by a medical oncologist who specializes in this and other forms of systemic therapy. The risks may depend on your individual circumstances and medical history, and it would be best to consult with a medical oncologist who specializes in prostate cancer.

pointer: Good day. I'm trying to get more information on treatment options concerning "ductal carcinoma" of the prostate. It seems very rare, and there’s not a lot of information concerning this rare type of prostate cancer. I was diagnosed in December of 2015. Once diagnosed, I immediately took Eligard, the six-month injection. It has not metastasized; I took all the scans. Then I received radiation therapy, 45 standard treatments that ended August 2, 2016. Also, I received another injection of Eligard about two weeks ago, a three-month injection. I'm 63 years of age, and I follow up with my doctor in November of this year. All and any input would be appreciated.

Rahul_Tendulkar,_MD: Among the different types of prostate cancer, the "ductal" variety can be associated with more aggressive features. After the treatment you have had (which seems appropriate based on the information you provided), standard monitoring with regular PSA checks is appropriate.

jpz: I have been treated for prostate cancer beginning last December with Lupron injections for six months. In April, I had seed implants followed by radiation therapy that ended in July. I am still feeling the effects of fatigue, etc. How long will these effects generally last?

Anthony_Avallone,_MD: Your symptom of fatigue is most likely from the hormonal therapy rather than the radiation treatments. Hot flushes and some weight gain are also common side effects from hormonal therapy. I am assuming you are receiving hormones in combination with radiation for high-risk prostate cancer. If so, you will probably be receiving hormones for about two years after completing radiation. It will take about six to 12 months for the effects of hormones and the associated side effects to wear off after receiving your last Lupron shot.

Rahul_Tendulkar,_MD: I agree with Dr. Avallone. Fatigue can be due to a combination of your treatments, but the hormonal therapy probably has the longest-lasting impact. Unfortunately, there is no "magic pill" for this. Some studies have suggested that American (Wisconsin) ginseng root can possibly improve cancer treatment-related fatigue, although this trial was not specific to prostate cancer or the treatments you had.

afflicted2: Is Provenge treatment successful? Is hormone treatment better than castration in stage 4, when the PSA is over 1000 and the cancer is hormone-resistant?

Rahul_Tendulkar,_MD: Once a prostate cancer develops resistance to hormonal therapy, additional systemic therapies become more important. There are a number of new treatment options that have become available in recent years, including docetaxel-based chemotherapy, enzalutamide, abiraterone, sipuleucel-T and radium-223. It’s best to speak to your medical oncologist about which next step is the right one for you.

Knowledge Seeker: Hello. My father is 87, and he has prostate cancer. Several years ago, he had a seed implant, but recently, the cancer appears to have spread to bone in the spine area, and he is losing weight. What treatment options should he consider?

Anthony_Avallone,_MD: Your father will need careful evaluation and close follow-up, especially as he has disease in the spine. In general, metastatic prostate cancer is treated with hormonal therapy, and the majority of patients respond to this treatment. Whether or not immediate or delayed hormonal therapy is required is an individualized decision that depends upon your father's clinical condition. This should be a decision made between your father and his doctor.

browning7: Is Provenge a proven beneficial treatment?

Rahul_Tendulkar,_MD: For select patients with metastatic prostate cancer, one trial showed that Provenge improved overall survival rates. However, it is a costly treatment and there are several other options that may be available in this setting. Ongoing studies will hopefully determine which is the best order or combination of therapies.

Second Opinions

MURupp: Can you suggest any doctors, hospitals, location, etc., for a second opinion? What is the procedure for the second opinion? Thanks.

Cleveland Clinic: We offer two options for a second opinion at Cleveland Clinic:

  1. Make an Appointment: To make an appointment with a Cleveland Clinic prostate cancer specialist, please call 866.223.8100 or visit
  2. MyConsult Online Second Opinion Service: This service allows you to consult one of our medical specialists without leaving your house. To learn more, call 800.223.2273, ext. 43223, or visit


That is all the time we have for questions today. Thank you, Dr. Avallone and Dr. Tendulkar, for taking time to educate us about prostate cancer treatment.

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