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Dr. Lin's Quest beyond Medication and Surgery               

    Overview
    on PSA and its Use as well as Prostate Cancer and its Diagnosis, Treatment, Follow-Up

    Nowadays the pace of change and evolution has moved faster than ever due to the ever-increasing speed of communication and
    transportation.

    Likewise, it happens to every field and aspect of life and medicine, especially in the field of diagnosing and treating prostate cancer.

    To make the patients, their family members, and the concerned wade through the constant swirling pond and moving flood of
    knowledge and information about prostate cancer, Dr. Lin has collected and organized the available information on the subjects for
    your convenience.

    At one place, you will learn and gain the much updated information about intelligent use of PSA (prostate specific antigen), reasonable
    screening, diagnosis, evaluation, treatment, and follow-up for prostate cancer; thereby, prostate cancer-related anxiety and fear can be
    timely and adequately eased and contained along the path of life.

    1. PSA Stories since its discovery in 1970 - its overuse, misuse, abuse, and reasonable use

    2. Risk of prostate cancer - How Lethal is Prostate Cancer?
  • Cancer cells move and spread to near and/or far sites, where may vary depending on its origin and types of primary organs; for
    prostate cancer, chiefly to nearby (regional) lymph nodes, to far sites - lungs, ribs, spine, pelvis, hips, etc.
  • Experience has proved that most patients with prostate cancer will die of other causes - not prostate cancer per se.

    3. Diagnosis - How to diagnose prostate?
  • Professional diligence and vigilance in keen use and application of PSA and DRE (digital rectal examination)
  • Do prostate ultrasound exam and biopsy as needed - not for every men - as alluded above.

    4. Decision-making for diagnosis, treatment, follow-up
  • Do not let the notion and push of "I would rather be safe than sorry." push too far leading to unnecessary care.
  • Always balance the equation between medical necessity and professional possibility.
  • Medical necessity is derived from two perspectives: 1. from patients, family, & relatives, it tends to be emotionally subjective and
    2. from medical professionals, it should be kept as professionally objective as possible. Combining emotional subjectivity and
    professional objectivity will come to a best possible reasonable decision to fit individual need.
  • Professional possibilities are the options of treatment and care. For prostate cancer, they range from active surveillance - watch
    and see, to surgical removal with open, laparoscopic, robotic approaches, to radiation therapy with external beam under
    various improved techniques, radio seed implant or brachytherapy, or combination of both, to cryotherapy (freezing), to judicious
    use of hormonal manipulation.
  • Try not to be a hind-sighted wise-person since we only allow to make a decision at a moment of life journey; life is a one-way
    street of accumulation, modification, and continuation as well as a constantly changing and adjusting dynamic process of
    struggle to cope with reality, certainty, and uncertainty of daily living; there is no magic in life and medicine, if any, that is to apply
    currently available knowledge, skill, technology, medication, common sense, and wisdom at reasonable time in reasonable
    way to reasonable patient.
  • Key contributing points (factors) to decide how to treat prostate cancer:
  1. age
  2. course of PSA change and evolution
  3. findings of DRE
  4. findings of transrectal ultrasound (TRUS)
  5. miscroscopic characteristics of cancer cells, known as Gleason score
  6. medical comorbidity
  7. patient's understanding and will to go along.

    5. Evaluation after diagnosis - How to evaluate patients after being diagnosed to have prostate cancer?
  • Not every patients require the same set of metastatic evaluation although imaging studies including bone scan, CT scan of
    abdomen and pelvis, and even MRI are commonly ordered.
  • In practice, the high demand of political correctness ("I would rather be safe than sorry:) and commercialism (money-making)
    has driven many professionals to order "unnecessary" tests; unfortunately, I am included so to meet the pressure of
    bureaucracy.
  • Note: imaging studies can not detect microscopic cancer spread. That is why many patients may be found to have cancer
    spread in follow-up as rising PSA after definitive treatment despite being informed that the bone scan, CT, or MRI showed no
    suspicion for metastasis (spread).

    6. Treatment Options
  • active surveillance
  • definitive treatment - intend to "cure"
  1. surgery - radical prostatectomy (RP) with open, laparoscopic, robotic-assisted approaches
  2. radiations
  1. external beam radiation therapy (EBRT) with improved techniques such as IMRT, or positron
  2. radio seed implant or called brachytherapy.
  3. possible combination of both, depending on stage of cancer and preferred protocol of the treating team.
  1. cryotherapy (freezing)
  • auxiliary (add-on) treatments
  1. hormonal treatment - commonly applied in conjunction with EBRT for 18-24 months or as the first line of treatment for
    clinically advanced (local or distant) cancer.

  • chemotherapy - judiciously use for metastatic prostate cancer after failed to hormonal treatment (manipulation).

    7. Follow-up - How to follow up prostate cancer after definitive treatment?
  • test PSA every 4 months for one year, then every 4-6 months,
  • do DRE in 3-4 months and afterwards as needed in light of rising PSA after definitive treatment
  • watch for rising PSA

       Despite receiving definitive treatment with intent to cure, some 35-50% of such treated patients will have
       so-called rising PSA which suggests three possibilities:
               1. local recurrence (failed to definitive treatment),
               2  spread to nearby tissue such as regional lymph node, or
               3. spread to far sites such as lungs, ribs, spine, pelvis, hips, etc.
            Note:
    It's just a form of radiation treatment for selected patients, not a fitting-all option, but designed and striven for better targeting
    accuracy and lesser collateral injury to the surrounding tissue around the prostate. So, don't let the word, CyberKnife, overdrive
    your expectation as something like a magic. It's not.
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PSA / its Use, Prostate
Cancer / its Care...
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