options appropriate for your individual situation. In other words, knowing that your cancer may be more aggressive can give you a better indication of how aggressively you want to have your cancer treated.
Prognostic Indicators To Discusss with Your Doctor
Age Age has very little impact by itself on whether or not you would qualify for or respond to an HRPC treatment. Overall, older men tend to respond just as well as younger men to HRPC treatment. However, younger men diagnosed with HRPC tend to have a worse prognosis simply because they have more aggressive tumors in some cases. And, since they are expected to have a longer life span, and since fewer currently have other health issues, HRPC does have a greater chance of eventually impacting them. In other words, older men are more likely to also have other serious diseases (co-morbidities, such as heart disease, diabetes, and other cancers) that could affect their lives during the time they are being treated for HRPC.
Albumin This is an important protein in the blood that is measured by a blood test. It serves as a carrier for all sorts of vital substances in the human body. A normal albumin level is a good indicator that the body is doing well when receiving treatment, but an abnormally low albumin level could be an indicator that the patient is not doing as well.
Alkaline Phosphatase A blood test for alkaline phosphatase measures the quantity of an important enzyme in the body that can help to predict the aggressiveness of your HRPC, as well as what the cancer is doing to your body. An abnormally high level of this enzyme tends to suggest that the cancer is being more aggressive and is not responding as well to treatment.
Asymptomatic or Symptomatic There are two distinctly different clinical stages within HRPC, namely, individuals who are asymptomatic (experiencing no symptoms at all) and symptomatic (experiencing some symptoms). Thanks to the PSA test and better imaging tests, the majority of men currently diagnosed with HRPC are asymptomatic. This is because the disease is being detected earlier and earlier, opening up more treatment options for HRPC patients. Men with asymptomatic HRPC have a better prognosis, in general. However, this may change somewhat in the future as more and more drug treatment options for men with symptomatic HRPC are in clinical trials right now.
Bone Metastasis and Number of Bone Metastases In general, individuals with HRPC who have bone metastasis (cancer that has spread to the bone) have a cancer that has progressed further than that of someone with no bone metastasis. Individuals with more bone metastasis could have a worse prognosis or a more serious HRPC, for the cancer has spread to more places in the body. In addition, when cancer spreads to unusual bone sites, such as the skull, new data suggest that such spread is associated with a more aggressive cancer.
Bone-Protecting Medication There is some preliminary indication in other types of advanced cancer that receiving a bone drug to reduce the risk of bone loss after being diagnosed may also reduce the risk of bone metastasis and improve survival. Studies are preliminary, but it appears that protecting your bones after being diagnosed with HRPC is critical to reducing the risk of bone loss that could delay your cancer treatment.
Circulating Tumor Cells The practice of monitoring circulating tumor cells (CTCs) to assess the effectiveness of a treatment or give some indication of prognosis is starting to get some attention. CTCs are epithelial cells that actually come free or are shed from different tumors. These CTCs can be counted in a new blood test (for example, “cell search”; see www.veridex.com). This test is being used in some clinical trials right now, and there seems to be an indication that when a drug causes a reduction in CTCs during treatment, or when there are fewer CTCs before the treatment, there is an increase in survival rates. This makes sense, because a reduction in tumor cells probably means that some cells have been destroyed. Ask your doctor about this new test if you are interested.
Diet, Lifestyle Changes, and Over-The-Counter Medicines Whether or not any diet or supplements could improve your HRPC prognosis specifically has not been proven, but a man who exercises regularly, eats a moderately healthy diet, and maintains a healthy weight may reduce his risk of getting other diseases that can reduce his life expectancy. A recent study of men diagnosed with HRPC found that a large number of men actually die yearly from other causes, such as cardiovascular disease. In the diet and supplement section of the book, you will find heart-healthy tips that may fight prostate cancer and a list of dietary supplements to consider taking or to avoid based on research on their likely effect on prognosis.
Gleason Total Score and Primary Gleason Score A higher total Gleason score (scores of 8 to 10, for example) indicates a more aggressive cancer. Prognosis or response to a drug could be worse for someone with this type of tumor as compared with someone who has a moderate or low Gleason score (below 8, for example). Most Gleason scores on tumors were established a long time ago for men with more localized disease, but knowing this number is still helpful in making treatment decisions. Some researchers believe that the first number in your Gleason score, called the primary Gleason score, is as important as the total Gleason score. For example, a primary Gleason score of 4 or 5 suggests a worse prognosis as compared to a primary score of 3. A man with a Gleason total score of 5 + 3 = 8 may have a worse prognosis as compared to someone with a score of 4 + 4 = 8.
Hemoglobin A hemoglobin count is a measure of the oxygen-carrying protein in your red blood cells. If hemoglobin is very low (a situation called anemia), a person may feel tired, and it will be more difficult for him to receive treatment. It is not unusual to be slightly anemic due to testosterone-lowering treatments, but an abnormally low hemoglobin level that causes a variety of symptoms (fatigue, breathing problems, etc.) may need to be treated. It can make the prognosis slightly worse by causing a delay in cancer treatments.
Hormone Treatment (LHRH, ADT, or Surgical Castration) As we discussed earlier, maintaining a castrate level of testosterone is recommended for most HRPC patients. This may provide both quality- and quantity-of-life benefits. But is it better to reduce testosterone by using regular LHRH injections, or just to have the testicles surgically removed? There has been no strong research to show that there is a survival or prognostic advantage of one method over the other. However, in some surveys of patients there seems to be a quality-of-life benefit for those who receive regular LHRH injections. Patients visit their doctors frequently to receive the injection, and that may be a positive thing. The injection may provide the patient with a feeling of control over the process and allow him to avoid surgery to permanently remove the testicles. It is worth noting that most patients who take LHRH injections for a period of time will not start to produce testosterone again, even if the injections are stopped. A patient who has to travel long distances to receive the injections may benefit from surgery.
Imaging Test Results X-rays, bone scans, CT scans, MRIs, or any other imaging tests that show that the cancer is spreading to more body sites tend to indicate that the cancer is more aggressive and not responding to treatment. Cancer that is not spreading or tumors that are shrinking in size are both good indicators that the patient is responding to treatment. (More information on imaging tests can be found at the end of this chapter.)
Lactate Dehydrogenase Also known as LDH, this is an important enzyme in the body that can be measured in a blood test and can help to predict the aggressiveness of your HRPC or what the cancer will do to your body. An abnormally high level of this enzyme tends to suggest that the cancer is more aggressive and is not responding as well to treatment.
Medical History and Co-morbidities It makes sense that your general health and any other diagnosed diseases (co-morbidities) can have an impact on your prognosis. Not surprisingly, individuals with other serious disease besides prostate cancer have a greater chance of dying younger. Individuals who are healthier in general and who have few to no co-morbidities tend to live longer. For example, obesity does not seem
