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Chris P
11-24-2010, 12:16 AM
One of my main characters has prostate cancer, and it's progressed enough to be life threatening before it is detected. In fact, it is caught too late and the character dies from it.

What would be the normal course of treatment for such a case? Surgery first, followed by chemo, and then radiation? Or are radiation and chemo done before surgery?

MaryMumsy
11-24-2010, 12:42 AM
A lot depends on the age of your MC and the stage/type of cancer. Ten years ago my Dad was diagnosed with prostate cancer. It was early stage and not especially aggressive and he was 75. After discussions with the urologist he opted for radiation. There was no chemo. The radiation was successful, but he was told it would probably only be good for around 5 years. Five years later, five years ago, his blood readings were up again. He has been taking hormone shots twice a year ever since and it is in remission.

Three and a half years ago my husband, age not quite 60, was diagnosed with a not advanced but aggressive prostate cancer. He had surgery, but no chemo or radiation. He has his blood work every six months and has had no recurrence.

It is my understanding that after radiation the hormone shots are the only option. Likewise with surgery. If it comes back my husband will need the shots.

The younger the man is, and the later it is caught, the more likely it will kill him. The actor Bill Bixby died of prostate cancer at a fairly young age. I'm sure one or more of the men here will chime in and have more in depth info.

MM

johnnysannie
11-24-2010, 01:37 AM
It would vary a great deal, as Mary Mumsy said, with a lot of variables. My father-in-law had prostrate cancer and he went to the Mayo Clinic where he had surgery, then chemo, and that worked until about three years later when he had cancer all through his abomen. That was the one that killed him despite doing heavy duty chemo/radiation options.

There just isn't any one size fits all treatment for any type of cancer, unfortunately.

cleanfreak
11-24-2010, 04:24 PM
Hi Chris P,

You might want to check out the National Cancer Institute's PDQ on prostate cancer:
http://www.cancer.gov/cancertopics/pdq/treatment/prostate/Patient/page4

They have a patient version and a physician version depending on how advanced you are. I am a certified tumor registrar so if you still have questions let me know, I may be able to answer them or at least point you in the right direction.

Some general points about prostate cancer:
-Has a tendency to metastasize to bone (and metastasis would almost certainly occur before death)
-Rarely diagnosed in men under age 40
-Grade, stage and PSA level (prostate-specific antigen) are the MAIN factors that determine likelihood of survival. Grade means how different the cancer cells look from the original prostate cells...poorly differentiated means they have changed a lot, and that's generally worse than well differentiated). Gleason score measures the grade.

Here are the 5-year survival rates for prostate cancer

100 percent for localized or regional stage
33.3 percent for distant stage
79.5 percent for unstaged.

So sorry if this is too much info. I hope that I helped you out a little.

boron
11-24-2010, 07:01 PM
Treatment of stage IV prostate cancer (http://www.cancer.gov/cancertopics/pdq/treatment/prostate/Patient/page5) (metastases in other organs) may include the following:


Hormone therapy (http://our.cancer.org/docroot/CRI/content/CRI_2_4_4X_Androgen_Suppression_Hormone_Therapy_36 .asp) alone (oral pills taken daily, or small implants given under the skin once a month) OR
Radiation therapy (http://www.california-impact.org/documents/palliative-rad.pdf) alone (about 15 minutes daily, Monday-Friday, for 1-3 weeks) OR
Hormone therapy followed by radiation therapy (http://www.medicalnewstoday.com/articles/32816.php) OR
Surgical removal of the prostate alone

All above options are meant as palliative measures to relieve pain. Chemotherapy is not widely accepted treatment of prostate cancer.

GeorgeK
11-24-2010, 07:49 PM
I'm a retired Urologist. There are basically at least 10 different types of primary prostate cancer (Gleason grades 2-10 plus anaplastic). The first step would be to determine which he has which requires a biopsy (usually done in the office after a limited bowel prep, oral antibiotics and without sedation) as well as blood tests prior to the biopsy. An ultrasound probe is inserted through the rectum and needle biopsies are taken, (6-12 typically).

Depending upon those results and the overall health of the patient surgery might be considered if it looks like a potentially curable kind. That often will require X-Rays to stage the disease first. Often that is a nuclear bone scan and a cat scan. There were some more advanced nuclear tests in study trials when I retired. I don't know if those panned out.

If those results show non-organ-confined disease (obvious spread outside the prostate) then curative sugery is out of the question, but sometimes there are debulking surgeries to help with the morbidity particularly if there is significant voiding trouble. Sometimes you do a pelvic lymph node dissection for both staging and to place metal staples around the prostate to make it easier for the radiation therapy to gauge the borders. There's a lot of potential things one might do.

With the Gleason Grade cancers, as the number gets higher, the more aggressive the cancer is. Low grade ones often just require observation. Sugically incurable ones typically get a combo of hormonal therapy plus or minus radiation, and there are many forms that either of those might take, possibly including castration. Some times the really higher grade ones get chemo as well (especially the anaplastic).

If you want your character to die quickly he should have the anaplastic variety. Those typically don't respond to anything and some people believe radiation might actually speed it up. Those are prostate cancers that are so mutated away from their original parent organ that they typically stop making the tumor markers (PSA). So when the blood tests are going down, it can be a bad sign particularly if the patient is clinically deteriorating. The anaplastic are typically more locally aggressive causing urinary and bowel obstruction and direct invasion of pelvic bones. The Gleasons tend to have widespread bone metasteses, causing bone pain and pathologic fractures with marrow invlovement leading to anemia, shortness of breath etc.

What do you want for your character?

Chris P
11-25-2010, 06:00 AM
Thanks for all the detail, everyone.

GeorgeK: The story plays out that the cancer is too far gone to remove simply, and the character dies about a year to 18 months after it is first discovered. There is an initial scene where he is recovering from some sort of procedure (a surgical attempt to remove the cancer?), returns to work but then his health deteriorates, finally dying in his home being cared for by a hospice worker. I'm not sure what type of procedures he could undergo in the meantime. I imagine I can leave things vague--he's got prostate cancer that's spread--but I need enough detail to make it realistic.

GeorgeK
11-27-2010, 07:30 PM
For most prostate cancers, think of testosterone as fertilizer for the cancer. Cancers resemble their original parent organ and so usually will respond to the same things that affect the parent organ. As the cancer mutates more and more, it starts to behave and react less like the parent and in the worst cancers ceases to resemble or behave at all like the parent. Normal prostates react to testosterone by having growth stimulated. Therefore most prostate cancers also react to testosterone (and or the lack of testosterone) and will shut down in the face of deprivation of testosterone. In the really nasty prostate cancers, the cancer has mutated to the point that it is no longer "prostate".

If you want him to get briefly better with an initial response to treatment, it would be more likely that he has a high grade Gleason cancer. Those usually do have some degree of hormone sensitivity and the fastest simplest and safest way to get them out of a bone crisis is an orchiectomy (castration) followed by pills to block testosterone pruction at the level of the adrenals. The problem with meds to block testicular testosterone is that there is a brief surge in testosterone production before chemical castration takes place and if someone has significant bone metasteses that brief surge can be enough to break the bones. Trying to fix pathologic fractures like those are very much a losing proposition. It is far better from a morbidity standpoint to avoid them. Fracturing a vertebrae from cancer is not your garden variety compression fracture like in osteoporosis. Cancer fractures can act more like a burst fracture and paralyze the patient.

The problem with hormone sensitive prostate cancers is that the high grade ones can often even become hormone resistant so that a year later the cancer seems to come back. The real mechanism is probably that there already was a small fraction of hormone resistent cancer present. The majority that was hormone sensitive gets shut down by treatment and stops competing with the other strain which can now grow unopposed. It's a similar theory to short term antibiotic resistence in bacteria.

Even though the initial castration helps with the pain and the patient can often return to normal activities within a week or two, with the high grade cancers it's common to go ahead and get an oncologist on board to oversee the radiation therapy and to intervene with chemo if and when the cancer starts growing out a hormone resistent strain.