PSA down to 0.3 – Bye, Bye Radiotherapy

Sam (not real name, H328) is 61 years old. He had been enduring urination problems for the past one year plus. Then in March 2010, there was a blockage, prompting him to seek doctor’s help. A tube was inserted and over a liter of urine was removed from his bladder.

A CT scan on 31 March 2010 indicated an irregular shaped prostate, 4.8 x 3.7 x 3.6 cm in size. Few calcification were noted in the prostate gland. The prostatic urethra appeared dilated. The bladder wall was thickened. A right iliac node was about 1.9 x 1.6 cm – indicating lymhphadenopathy.

A TURP (transurethral resection of the prostate) was performed.  This is a common surgical procedure to treat the enlargement of the prostate gland.  The histopathology report of the prostatic tissues indicated a poorly differentiated adenocarcinoma, Gleason grade 4, Total Gleason score: 4+4, Stage T2c. The perineural lymphatics were infiltrated.

His PSA on 31 March 2010 was 47.07.

Sam was prescribed hormonal pill which he took for about a week or two and then stopped. He decided to see another doctor in another hospital.  MRI on 3 April 2010 showed no evidence of bony or intracranial metastasis.

Sam was given two options: One, to receive hormonal injection every three months. Or two, to undergo an orchidectomy – i.e. to remove the testes. On the advice of his doctor friend, he opted for the latter, i.e. removal of both his testes.  After the surgery, his doctor asked him to undergo 35 times of  radiation treatment. This would cost RM 23,000 (the same treatment would cost RM 28,000 in Kuala Lumpur).

The PSA on 5 April 2010 was 33.18.

Sam declined radiotherapy. He came to seek our help on 28 May 2010. He was started on herbs and was asked to take care of his diet.  On 5 November 2010, Sam came back to see us again. His PSA on 20 September 2010 returned a reading of 0.3. He went to see his doctor and was told that there is no further need to do radiotherapy. Another PSA test needs to be done in two months time.

Comments: There are two issues involved in this case study.  One, let us look at the PSA readings again.

Date PSA
31 March 2010 47.07
5 April 2010 33.18
28 May 2010 Started on herbs + diet
20 September 2010 0.3

The question to ask: Is the drastic drop of the PSA due to the removal of his testes or due to the herbs? I went into the net to search for answers.

A paper written by doctors in Brazil said the following:

Most prostate cancers are hormone-dependent; this means that they need testosterone for disease progression. Ninety percent of testosterone is produced by Leydig cells of the testis, whereas adrenal glands account for 5% of this production. The simplest way to get a hormonal blockade is bilateral orchidectomy.

Between January 2001 and December 2001, 32 patients with advanced prostate cancer underwent bilateral orchidectomy at our Hospital. They had the following results:

  • 4 patients required anti-androgens after surgery to control rising PSA.
  • 27 patients had decreased PSA level. The lowest nadir obtained was 0.08 ng/mL.
  • 4 patients showed no PSA decrease 30 days after orchidectomy.

A paper written by doctors in India said:

  • Orchidectomy over the decade has been the most effective tool for lowering the circulating testosterone.
  • Prostate tumor may respond in a variety of ways to castration therapy (orchidectomy).
  • There is no definitive way to predict which patient will respond to orchidectomy.
  • PSA has been used as the clinical marker to monitor the disease.
  • In the present study, we recorded changes in PSA level after orchidectomy and it was evident that maximum percentage changes in PSA are seen in the first three months after orchidectomy.

In another research paper was this information.

  • A bilateral orchidectomy was performed.  In all 3 cases PSA and testosterone levels were reduced following castration, although PSA levels again began to increase within two weeks of orchidectomy in 2 of the 3 patients.

Further reading led me to what patients wrote in the chat rooms. The following are some examples.

One reader wrote:

My father has been recently diagnosed with Prostate Cancer. He underwent orchidectomny a month ago (by a local general surgeon). He is on Zometa on a monthly basis. The PSA before surgery was 160. Few days ago, the blood tests were done and his PSA was about the same, 160. I was wondering how quickly PSA will fall after orchidectomy? If it does not fall, what does it mean to the treatment?

A reader asked this question:

I’ve had an orchidectomy, so my testes don’t produce testosterone. My PSA is rising and my doctor has suggested that I get an injection of Lupron (or Zoladex). Why?

What are the after effects of an orchidectomy?

Orchidectomy causes sudden hormone changes in the body. Side effects from hormone changes include: Sterility, Loss of sexual interest, Erection problems, Hot flashes, Larger breasts (gynecomastia), Weight gain, Loss of muscle mass, Thin or brittle bones (osteoporosis).

Another reader wrote:

Besides the list of side effects that JCR gave you there are also upwards of 20 more. Some of these side effects are loss or reduction of short term memory, loss of strength, loss of body hair, possibility of having pain in joints and back, mood swings–some of which can be anger and/or increased sensitivity to situations that can result in crying.

What to think about.

Removing the testicles is one way to cut down on testosterone and other male hormones. Taking medicine is another way to reduce androgen levels in your body. Some men may prefer surgery over taking pills or having injections. But if you choose to take medicine, you can stop taking the hormone drugs. And the side effects from taking medicine may go away. An orchidectomy is permanent. Some men choose to have reconstructive surgery after an orchidectomy, in which the surgeon replaces the testicles with artificial testicles.

From the above information and discussion, it appears that undergoing orchidectomy makes sense to some people, because removal of the testes deprives the prostate of the hormone it requires. That is provided the patient can come to term with the idea that he is being castrated. As the doctor friend of this patient said – you are already old! But think again, is 61 years old a bit too young to do such a thing?

Another point to note is that not all orchidectomy leads to a drastic drop in the PSA. And also, a drop of PSA does not mean the disease is cured.

The second comment I wish to raise about Sam’s case is the idea of opportunity cost. This is something that I learned   in my economics class in the 1960s. The dictionary definition of opportunity cost is: The cost of an alternative that must be forgone in order to pursue a certain action. Put another way, the benefits you could have received by taking an alternative action.

Opportunity cost is one of the most important and fundamental concepts in decision making. We have to look at what sacrifices we make when we have to make a choice. Cost here implies something is being sacrificed or involves having to give up something.

So, opportunity cost is the process of choosing one good or service over another.  Even though you might not realize it, you use opportunity cost every single day – to make choices about what you do every day.

In Sam’s case, after surgery he was asked to undergo 35 times of radiation treatment at a  cost of RM 23,000. What could have happened if he were to follow his doctor’s advice? The material effect is, he would have to spend RM 23,000 for the treatment. With the treatment comes the various side effects which could be devastating or otherwise. His quality of life would be adversely affected in one way or another.  Then look at another direction. Sam turned to herbs. His PSA dropped to 0.3 and the doctor said Sam need not do radiotherapy anymore. How much good is the advice of doing radiotherapy then?

There is one danger that I can foresee.  Now that the PSA has gone down to 0.3, patient appears to be out of danger! It is hard to convince him that this is not a cure. The cancer might recur. After some months, most patients go back to their old ways again.