Politico
© August 31, 2010
By David Rogers
Age and Agent Orange are closing in on Vietnam veterans, a legacy of hurt for those who served — and a very big bill for American taxpayers.
It’s a world turned upside-down from decades ago when returning soldiers had to fight to get attention for deadly lymphomas linked to the herbicide. Now the frailties of men in their 60s — prostate cancer, diabetes, heart disease — lead the list of qualified Agent Orange disabilities, and the result has been an explosion in claims — and the government’s liability.
The latest expansion, approved by Veterans Affairs Secretary Eric Shinseki in October, adds ischemic heart disease and Parkinson’s and will cost at least $42 billion over the next 10 years. The VA estimates 349,000 individuals are already receiving Agent Orange disability benefits and that number could soon reach 500,000 — or one out of every four surviving Vietnam veterans by the VA’s count.
As the costs rise, so do the questions about the science involved and the box Washington put itself in by failing to address Agent Orange’s impact more directly at the outset.
And because Vietnam service is still such a political minefield for American politicians, the most telling, often edgy debate is among veterans themselves.
“It is what it is. The anecdotal evidence of Vietnam veterans dying and getting diseases earlier is enormous,” said an exasperated Richard Weidman, an Army medic in the war and now legislative director for Vietnam Veterans of America. “I know five people in the VVA leadership alone who have been diagnosed with Parkinson’s. In no other side of my life have I seen anything like that.”
Yet for many who saw Vietnam firsthand, a 1-to-4 ratio of service-connected disabilities for Agent Orange strains credibility. And this is especially the case when the top conditions are heart disease and diabetes, two illnesses so linked to diet and lifestyle.
“Heart disease is a common phenomenon regardless of potential exposure to Agent Orange,” wrote Sen.Jim Webb (D-Va.) in a June letter to Shinseki challenging the secretary’s decision. A decorated Marine infantry officer in the war, Webb has since softened his tone after catching heat for his stance. But with his urging, the Senate Veterans Affairs Committee has scheduled a hearing Sept. 23 on the new regulations, slated to take effect by December.
“I just want to understand the logic of how they decided this latest service connection,” said Webb. “This is a helluva awkward position to be in where I’ve been an advocate all my adult life on veterans’ benefits. I just want to know how they got to this point.”
Backing Webb is Anthony Principi, also a Vietnam veteran, and the VA secretary under President George W. Bush.
“He’s gotten some heat, but how can anyone question his patriotism and what he has done?” Principi said of Webb. “It’s got to be looked at; it’s got to be addressed. ... This is serious. The numbers are dramatic.”
“We’re 40 years later and we need to ask, is there a better way to do this? You want to do what’s right for veterans,” he told POLITICO. “At the same time, you want to protect the integrity of the disability compensation program.”
The convergence of cost pressures now is striking as captured by events on Tuesday this week.
That morning, the VA expects the Federal Register to publish the new Agent Orange rules to implement the latest expansion of benefits, including heart disease coverage. And that evening, President Barack Obama will speak to the nation on the U.S. transition between Iraq and Afghanistan, two fresh post-Vietnam wars with their own legacy of new disability claims.
In fiscal 2005, the annual cost of VA’s compensation obligations was $28.6 billion; for fiscal 2011, the number’s $48.8 billion — a $20.2 billion or 71 percent increase.
Still more worrisome is the government’s long-term unfunded liability, a number tucked away in VA’s annual financial reports. The latest for Sept. 30, 2009, shows an unfunded liability of $1.32 trillion for VA’s compensation and pensions account. That’s up almost $400 billion from $924 billion in a matter of five years.
Yet for many Vietnam veterans, now in their 60s and approaching retirement, the tax-free disability payments represent a valuable supplement to Social Security.
In the case of ischemic heart disease, VA is assuming that most claims will be treated as a 60 percent disability, which translates into about $1064 per month for a married veteran. If the same veteran were already on 20 percent disability for diabetes, the payment could be $1,333 or almost $16,000 annually.
The VA calculates that IHD claims will account for three-quarters — about $31.2 billion — of the 10-year costs associated with the latest expansion. Disability percentages are typically lower for diabetes, but the sheer number of claims — more than 239,000 since 2002 — dwarfs all others before heart disease was added.
For example, prostate cancer generated about 57,300 claims in the same period by VA’s count; lung cancer less than 11,600 and non-Hodgkin’s lymphoma half that again.
Congress will have 60 days to review the regulations put forward by Shinseki, but lawmakers already approved a $13.6 billion down payment to cover retroactive claims related to the secretary’s ruling. And with November’s election around the corner, no one expects a major rollback.
“The horse is out of the barn, it’s a mess.” said one outside scientist who has worked with VA on Agent Orange claims. House Veterans Affairs Committee Chairman Bob Filner (D-Calif.) would go even further, extending the same disability benefits to thousands more veterans, such as “blue water” sailors who served on ships off the Vietnam coast.
“We owe this. It’s like a debt in my opinion,” Filner told POLITICO. “My motto is if you were there, we care.”
Indeed few topics touch more raw nerves at once: the bitter history of the Vietnam War, the often bad treatment of soldiers returning and the military’s early refusal to come to grips with the health impacts of its unprecedented use of the herbicide.
Agent Orange, which got its name from the orange-colored band on the storage barrels in Vietnam, was the most common of several dioxin-contaminated herbicide blends employed in Indochina over an almost 10-year period during the war. Literally thousands of tons were sprayed by the U.S. to try to destroy the jungle canopy and mangroves but also to clear tall grasses around American fire support bases.
It follows that exposure was greatest for those assigned to the spraying or in combat infantry units on the ground underneath — a fraction of the total U.S. force. But after a period of denial, the government gave up sorting out military records and said any veteran who put “boots on the ground” in Vietnam from early 1962 to May 1975 would be presumed exposed.
“Do you deny the deserving, or do you include in the presumption those people who may not have been exposed?” adds Dr. Victoria Cassano, a senior VA official dealing with environmental agents and Agent Orange. “The greater evil is to deny people who deservedly should be compensated for diseases because of this exposure.”
But Principi admits he still struggles with his role in what proved a sea change in policy, adding Type 2 diabetes to the list of presumed Agent Orange disabilities. The regulations were among the first order of business on his desk when he arrived in 2001, and from his war experience and prior service in VA, the new secretary brought with him an emotional tie to the late Adm. Elmo Zumwalt, who commanded Navy swift boat forces in Vietnam and watched his own son — a Navy Vietnam veteran as well — die of a cancer that the father attributed to Agent Orange exposure.
“It puts secretaries in a very untenable position,” Principi said. “I didn’t really care about the cost, our responsibility was to take care of veterans. But at the same time, I wanted to make sure the science was there and I just struggled with it.”
In fact, there’s a real disconnect between the outside scientists who advise the VA and the decision makers themselves. Congress can be faulted for the loose standard of proof it set in the 1991 Agent Orange Act to guide the process. But without more science — especially studies of veterans themselves — the integrity of the disability process is vulnerable to attack.
The chief outside actor is the Institute of Medicine within the National Academy of Science. Every two years since the mid-90s, IOM has produced detailed reports — volumes as thick as 682 pages with recommendations and updates of what scientists worldwide have learned relevant to Agent Orange’s impact.
Over time, these reports have led to a steady expansion of the diseases presumed to be associated with exposure to the herbicide. But often IOM and the VA seem to talk past one another as to what the science means.
“You are asking for the balancing of two different value systems, to come up with an answer and address a harm done to a person,” said Dr. Jeanne Stellman of Columbia University who has done extensive research on Agent Orange. “How do you translate science into law and policy?”
“The decision is very easy if it says no or if it says absolutely. In between is when there is imprecision,” said Dr. Robert Jesse, VA’s principal deputy undersecretary for health. And that comes often comes back to this question: What does IOM really mean when it says there is “limited or suggestive evidence of an association” between a disease and exposure to Agent Orange?
To hear IOM tell it, the category was never meant to be all decisive but more of a middle niche: “Something might be emerging here, something to keep an eye on,” one scientist told POLITICO. Along the same lines, a special IOM panel in 2008 went back and looked at the 2001 decision on diabetes and argued that the VA would have done better to test the association against “high-quality data for a representative cohort of veterans.”
VA officials answer that they are bound by the legal construct of the 1991 Agent Orange Act, which requires the secretary to respond within 60 days to any evidence of a positive association cited by IOM — however tentative.
“We can’t dismiss it,” said Cassano. “We have to take it as a positive association even though it states it as the lowest level of a positive association. We have to consider it credible.”
Asked if she were comfortable, as a scientist, with an end result where one in four Vietnam veterans could soon be getting service-connected Agent Orange disability payments, Cassano didn’t back down.
“Yes,” she said flatly. “We are comfortable with it; it is the right thing to do; it is the legal thing to do. ... When you are working in the VA and you have statutory requirements and basically a directive, a mission to be advocates for veterans, you are therefore bound by those parameters, and it really doesn’t matter much what outside scientists say.”
A closer look at Shinseki’s decision on IHD illustrates some of these conflicts.
It was a 14-member panel for the IOM, which set the ball rolling in its 2008 update, released last year. A similar panel in 2006 had been divided on the heart disease question, but after revisiting the question, IOM elevated the illness to the category of “limited or suggestive evidence of association.”
That decision was driven in part by newly published evidence showing a dose-response curve: the greater the exposure to Agent Orange, the greater occurrence of heart ailments. “When you see a dose-response curve, then you are much more inclined to be thinking causal,” said Jesse.
The VA had contributed an important piece with a 2006 study analyzing the incidence of heart disease among Vietnam veterans who had served in the Army Chemical Corps. And Shinseki, who himself served in Vietnam, found that this built on well-established evidence that dioxins present in Agent Orange could damage blood vessels. “Veterans who endure health problems deserve timely decisions based on solid evidence,” he said.
Nonetheless, the leader of the IOM panel, Dr. Richard Fenske of the University of Washington, told POLITICO that he was “surprised by the speed” with which the VA decided to add the presumption for heart disease. And Weidman argues that the department repeatedly ignores what he sees as a central tenet of the 1991 law: that more should be invested in scientific studies of veterans themselves.
“The whole concept of the 1991 law was to leave it to science, not politics, but we haven’t invested in the science in the 20 years since,” he said. In a shot back at Webb, he adds: “If you want more scientific data, fund the damn science.”
For all the debate over Agent Orange, what’s most surprising is how little or no effort has been made to track down specific infantry units that operated in the widely sprayed areas of Vietnam.
Instead, decisions are more often dependent on extrapolating data from studies of other populations: European and Asian chemical and agricultural workers, for example. The VA study of the Army Chemical Corps stands out for at least being Vietnam-centric. But even here, the focus did not include the great many more ground troops who were not involved in the actual spraying.
With so many claims on file now, the VA could yet work backward, identifying what units veterans served with in the war and their location in respect to the spraying. “The associations may be very much stronger if we really had the proximity data of where people served,” Jesse said. But to his frustration, Weidman has found that the VA’s health data is kept in a manner where this is not easily searchable. “They don’t want to know,” he said.
The biggest new effort is an old one: After almost a decade of delay, the VA is preparing to make another run at the long-promised National Vietnam Veterans Longitudinal Study to take a broad view at lasting health problems. A contract is expected to be awarded this fall, and, if successful, this could be the broadest assessment of ongoing Vietnam veteran health problems since the late '80s.
But the more lasting impact of the Agent Orange experience may be on the treatment of future veterans — not Vietnam’s.
At the end of a long interview, VA officials perk up most when the subject turns to VLER — their new “virtual lifetime electronic records” initiative to track each future veteran’s health charts from enlistment to grave. Included would be data from the military as to what toxic threats a soldier might be exposed to; “We will be able to know what levels of exposure there were to chemicals,” said Cassano.
And did Agent Orange influence this?
“Oh, certainly it has,” she said.
Sunday, January 9, 2011
Thursday, January 6, 2011
NCCN Prostate Cancer Treatment Guidance, 2011
Prostate cancer is the most common cancer in men, with lung cancer the second most common. Because of significant improvements in screening and early detection of prostate cancer over the past 30 years, the outlook for many men diagnosed with this disease has improved.
If you have been diagnosed with prostate cancer, you probably have many questions. How it is likely to be treated? What happens when treatment is completed? This overview, which is based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for prostate cancer, will help you understand the treatments available for prostate cancer. Talk to your doctor about these options so that together you can decide on a treatment plan that is right for you.
BackgroundThe prostate gland lies just below the bladder and produces a fluid that forms part of the semen. Men older than 65 years, those with a family history of prostate cancer (especially if a brother or father has been diagnosed with prostate cancer), and those of African descent are at higher risk for prostate cancer.
Screening for Prostate CancerMany men are choosing to be screened for prostate cancer using prostate-specific antigen (PSA) testing and digital rectal examination (DRE). The decision about whether to be screened is personal, but it should be based on an understanding of the potential risks and benefits of screening. Risks include discomfort, the possible side effects if a biopsy is done, and the physical and mental implications of finding out you have a cancer that may not pose a threat to your life. Benefits include finding prostate cancer at its earliest and most treatable stages.
Experts estimate that deaths from prostate cancer have decreased 40% since PSA testing became widespread in 1992. At the same time, there is a lot of disagreement about the value of early diagnosis with PSA testing. This is because many of the cancers found with screening will probably never pose a threat to a man’s life. Therefore, some men may undergo treatment that has no benefits to their life expectancy---in other words, these men will live as long as they would if they did not have prostate cancer, and the side effects of treatment could decrease their quality of life.
Prostate cancer often can be present for a long time before any symptoms appear. However, some aggressive and life-threatening cancers will be found through screening and therefore will be treated before they can spread. The greatest benefits of screening are for men at high risk for prostate cancer either because of family history or African-American descent. Benefits of screening are also most significant in men younger than 70 years.
Diagnosis of Prostate CancerProstate cancer rarely causes any symptoms until it is advanced and usually incurable. However, prostate cancer may be suspected for several reasons, including:
A lump in the prostate gland or an asymmetric prostate
Inability to pass urine
Difficulty starting or stopping the urine flow
Need to urinate often, especially at night
Weak flow of urine
Urine flow that starts and stops
Pain or burning during urination
Difficulty having an erection
Blood in the urine or semen
Frequent pain in the lower back, hips, or upper thighs
Suspicious findings from a DRE or PSA test do not necessarily mean that a man has cancer, and the symptoms above are not always caused by cancer (they can also be caused by a noncancerous condition called benign prostatic hyperplasia, or BPH.
To determine whether symptoms or an abnormal DRE or PSA results are caused by benign enlargement or prostate cancer, the doctor will perform a biopsy, often called a transrectal biopsy, under ultrasound guidance. In this procedure, the prostate is viewed using a probe the size of a finger inserted in the rectum. Tissue is removed with small needles from many areas of the prostate and examined under a microscope to look for cancer cells. This is the only way to specifically diagnose prostate cancer; an elevated PSA or abnormal DRE does not necessarily mean you have prostate cancer.
More Testing
If the biopsy indicates that you have prostate cancer, tests may be done to find out how aggressive the cancer may be. You may be scheduled for tests that will help your doctor determine whether your tumor is confined to the area where it began (that is, it is localized) or whether it has spread (that is, it has metastasized). Your doctor also will take a detailed medical history and may request other tests to determine your health and whether certain treatments are appropriate for you.
More tests may be ordered depending on how large the tumor is, your PSA level, and the Gleason score of your tumor. The Gleason score or grade is scaled to the aggressiveness of the prostate cancer. The Gleason grade is determined by a pathologist using a microscope to examine your cancer; it reflects the ability of the cancer to form glands. Generally, the lower the score, the more likely the tumor is growing slowly and the less likely it is to spread.
Additional tests may include:
A radionuclide bone scan to see whether cancer cells have spread to the bone
Magnetic resonance imaging (MRI) and/or computed tomography (CAT or CT scan) to show detailed images of the insides of the body
A pelvic lymphadenectomy, which is a surgical procedure to remove lymph nodes in the pelvis to see whether cancer has spread to these nodes
Each of these procedures provides information about grade and characteristics of the cancer that is important for determining the stage of your disease. Knowing the stage of your disease, in turn, is vital to determining which treatment program promises the best results.
Staging of Prostate Cancer A formal system called staging is used to identify how localized or widespread your cancer is. Prostate cancer stages range from stage I (most localized; cancer cells are only in the prostate) to stage IV (cancer cells have spread to distant lymph nodes and/or organs in your body, including the bones).
Staging is an important part of developing the best treatment plan for you.
For a more detailed discussion of staging, see the Cancer Staging Guide.
An elevated Gleason score and an elevated PSA level indicate that the cancer is likely to spread and that there is an increased chance that it might recur (come back) after treatment. This risk (or chance) of recurrence is another important factor in making treatment decisions.
Risk of Prostate Cancer Recurrence The risk that cancer may recur after treatment is a significant consideration in the treatment decisions patients make with their doctors. Many factors influence the risk that prostate cancer might recur. Among the most important are the size and location of the tumor; the PSA level in your blood; how fast the cancer cells are growing; and how far, if at all, the cancer has spread from the place where the tumor began. Many prostate cancers, especially in older men, are relatively slow-growing and may not have an impact on their lifespan or general health. Others, however, are quite aggressive and can spread to the bones and vital organs.
In recommending a treatment for you, your doctor will estimate how long you likely would live if you didn’t have prostate cancer based on your age and general medical condition (this is much the same process an insurance company uses in determining life insurance rates). Then, based on factors specific to your tumor, he or she will estimate how long it would take for your prostate cancer to become life-threatening to you. These two time periods are compared to help decide whether the prostate cancer is likely to reduce your lifespan and whether treatment is recommend.
Your doctor will review the results of your PSA test (and PSA tests that you had in the past, if any) to help determine how quickly your cancer is growing. The PSA level at the time your cancer is discovered is an important indicator. Generally, higher values indicate more aggressive cancer.
Additional important information may be obtained from the length of time it takes for your PSA value to double. For this “doubling” test to be valid, you must have had three separate PSA tests over a period of at least 18 months. In general, the faster the doubling time, the more aggressive the cancer. Some men with early-stage prostate cancer will have had enough tests over time for the doctor to compute this doubling time, but many will not have had enough PSA tests.
In addition to assigning a stage as described above, your doctor will also assign a Gleason score for your disease. This score, which ranges from 2 to 10, is a measure of the aggressiveness of your tumor. The pathologist assigns a number from 1 (least aggressive) to 5 (most aggressive) to the most frequently occurring appearance of cancer cells in the tissue sample used in the biopsy and the next most frequently occurring appearance of cancer cells in that tissue sample—this second sample is also assigned a score ranging from 1 to 5. The two scores are added together to get the Gleason score. The higher the score, the greater the chance that the cancer will (or already has) spread.
Based on your PSA level, cancer stage, and Gleason score, your doctor will estimate how likely the cancer is to grow and spread. Because all treatments for cancer can cause side effects, doctors aim to give patients treatments that will cause the fewest side effects while effectively curing the cancer. In some cases, the risk of the cancer getting worse may be relatively small compared with the side effects of treatment. However, when the risk is high that the cancer will grow quickly or recur after treatment, doctors may prescribe aggressive treatment to reduce that risk.
Treatment of Prostate CancerThe effectiveness of treatment depends on how localized the cancer is and whether or how far it has spread in your body. Depending on the stage of your disease and the other indicators discussed above, the characteristics of your tumor, and your age and general health, your doctor will recommend one or more of the following: active surveillance (also called observation, expectant management, or watchful waiting), surgery, radiation therapy, hormone therapy, chemotherapy, or targeted therapy. These options are discussed in the treatment summaries for localized prostate cancer and advanced prostate cancer.
Because some forms of prostate cancer treatment can cause infertility, if you want to father children you may want to discuss sperm banking before treatment begins. Your doctor can help you with this consideration.
Life After Prostate Cancer Treatment After completion of your treatment, you will begin a period called follow-up. During this period, you will visit your doctor at regular intervals. The doctor will perform a physical exam, ask you about how you are feeling, and order tests to make sure that you remain healthy and that any long-term effects of your prostate cancer or its treatment can be addressed. See Taking Care of Follow-Up Care.
NCCN.com Thanks Our Supporters:
ResourcesNCCN Physician Guidelines
NCCN Cancer Resources
NCCN Cancer Answers
Clinical Trials
FAQs
Glossary
Ask Jai
Advice For Caregivers Coming soon, Jai Pausch, widow of Randy Pausch, author of the internationally acclaimed best-selling book, The Last Lecture (see the video here), will share her experience and wisdom as a cancer caregiver. The new monthly column, “Ask Jai,” will offer real-world advice on coping with cancer’s challenges, managing your own life, and helping those you care for.
Have a concern or question to share? Email Jai at askjai@nccn.org.
NCCN Member Institutions
The National Comprehensive Cancer Network (NCCN) is a not-for-profit alliance of 21 of the world’s leading cancer centers. We are dedicated to improving the quality and effectiveness of care provided to people with cancer.
If you have been diagnosed with prostate cancer, you probably have many questions. How it is likely to be treated? What happens when treatment is completed? This overview, which is based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for prostate cancer, will help you understand the treatments available for prostate cancer. Talk to your doctor about these options so that together you can decide on a treatment plan that is right for you.
BackgroundThe prostate gland lies just below the bladder and produces a fluid that forms part of the semen. Men older than 65 years, those with a family history of prostate cancer (especially if a brother or father has been diagnosed with prostate cancer), and those of African descent are at higher risk for prostate cancer.
Screening for Prostate CancerMany men are choosing to be screened for prostate cancer using prostate-specific antigen (PSA) testing and digital rectal examination (DRE). The decision about whether to be screened is personal, but it should be based on an understanding of the potential risks and benefits of screening. Risks include discomfort, the possible side effects if a biopsy is done, and the physical and mental implications of finding out you have a cancer that may not pose a threat to your life. Benefits include finding prostate cancer at its earliest and most treatable stages.
Experts estimate that deaths from prostate cancer have decreased 40% since PSA testing became widespread in 1992. At the same time, there is a lot of disagreement about the value of early diagnosis with PSA testing. This is because many of the cancers found with screening will probably never pose a threat to a man’s life. Therefore, some men may undergo treatment that has no benefits to their life expectancy---in other words, these men will live as long as they would if they did not have prostate cancer, and the side effects of treatment could decrease their quality of life.
Prostate cancer often can be present for a long time before any symptoms appear. However, some aggressive and life-threatening cancers will be found through screening and therefore will be treated before they can spread. The greatest benefits of screening are for men at high risk for prostate cancer either because of family history or African-American descent. Benefits of screening are also most significant in men younger than 70 years.
Diagnosis of Prostate CancerProstate cancer rarely causes any symptoms until it is advanced and usually incurable. However, prostate cancer may be suspected for several reasons, including:
A lump in the prostate gland or an asymmetric prostate
Inability to pass urine
Difficulty starting or stopping the urine flow
Need to urinate often, especially at night
Weak flow of urine
Urine flow that starts and stops
Pain or burning during urination
Difficulty having an erection
Blood in the urine or semen
Frequent pain in the lower back, hips, or upper thighs
Suspicious findings from a DRE or PSA test do not necessarily mean that a man has cancer, and the symptoms above are not always caused by cancer (they can also be caused by a noncancerous condition called benign prostatic hyperplasia, or BPH.
To determine whether symptoms or an abnormal DRE or PSA results are caused by benign enlargement or prostate cancer, the doctor will perform a biopsy, often called a transrectal biopsy, under ultrasound guidance. In this procedure, the prostate is viewed using a probe the size of a finger inserted in the rectum. Tissue is removed with small needles from many areas of the prostate and examined under a microscope to look for cancer cells. This is the only way to specifically diagnose prostate cancer; an elevated PSA or abnormal DRE does not necessarily mean you have prostate cancer.
More Testing
If the biopsy indicates that you have prostate cancer, tests may be done to find out how aggressive the cancer may be. You may be scheduled for tests that will help your doctor determine whether your tumor is confined to the area where it began (that is, it is localized) or whether it has spread (that is, it has metastasized). Your doctor also will take a detailed medical history and may request other tests to determine your health and whether certain treatments are appropriate for you.
More tests may be ordered depending on how large the tumor is, your PSA level, and the Gleason score of your tumor. The Gleason score or grade is scaled to the aggressiveness of the prostate cancer. The Gleason grade is determined by a pathologist using a microscope to examine your cancer; it reflects the ability of the cancer to form glands. Generally, the lower the score, the more likely the tumor is growing slowly and the less likely it is to spread.
Additional tests may include:
A radionuclide bone scan to see whether cancer cells have spread to the bone
Magnetic resonance imaging (MRI) and/or computed tomography (CAT or CT scan) to show detailed images of the insides of the body
A pelvic lymphadenectomy, which is a surgical procedure to remove lymph nodes in the pelvis to see whether cancer has spread to these nodes
Each of these procedures provides information about grade and characteristics of the cancer that is important for determining the stage of your disease. Knowing the stage of your disease, in turn, is vital to determining which treatment program promises the best results.
Staging of Prostate Cancer A formal system called staging is used to identify how localized or widespread your cancer is. Prostate cancer stages range from stage I (most localized; cancer cells are only in the prostate) to stage IV (cancer cells have spread to distant lymph nodes and/or organs in your body, including the bones).
Staging is an important part of developing the best treatment plan for you.
For a more detailed discussion of staging, see the Cancer Staging Guide.
An elevated Gleason score and an elevated PSA level indicate that the cancer is likely to spread and that there is an increased chance that it might recur (come back) after treatment. This risk (or chance) of recurrence is another important factor in making treatment decisions.
Risk of Prostate Cancer Recurrence The risk that cancer may recur after treatment is a significant consideration in the treatment decisions patients make with their doctors. Many factors influence the risk that prostate cancer might recur. Among the most important are the size and location of the tumor; the PSA level in your blood; how fast the cancer cells are growing; and how far, if at all, the cancer has spread from the place where the tumor began. Many prostate cancers, especially in older men, are relatively slow-growing and may not have an impact on their lifespan or general health. Others, however, are quite aggressive and can spread to the bones and vital organs.
In recommending a treatment for you, your doctor will estimate how long you likely would live if you didn’t have prostate cancer based on your age and general medical condition (this is much the same process an insurance company uses in determining life insurance rates). Then, based on factors specific to your tumor, he or she will estimate how long it would take for your prostate cancer to become life-threatening to you. These two time periods are compared to help decide whether the prostate cancer is likely to reduce your lifespan and whether treatment is recommend.
Your doctor will review the results of your PSA test (and PSA tests that you had in the past, if any) to help determine how quickly your cancer is growing. The PSA level at the time your cancer is discovered is an important indicator. Generally, higher values indicate more aggressive cancer.
Additional important information may be obtained from the length of time it takes for your PSA value to double. For this “doubling” test to be valid, you must have had three separate PSA tests over a period of at least 18 months. In general, the faster the doubling time, the more aggressive the cancer. Some men with early-stage prostate cancer will have had enough tests over time for the doctor to compute this doubling time, but many will not have had enough PSA tests.
In addition to assigning a stage as described above, your doctor will also assign a Gleason score for your disease. This score, which ranges from 2 to 10, is a measure of the aggressiveness of your tumor. The pathologist assigns a number from 1 (least aggressive) to 5 (most aggressive) to the most frequently occurring appearance of cancer cells in the tissue sample used in the biopsy and the next most frequently occurring appearance of cancer cells in that tissue sample—this second sample is also assigned a score ranging from 1 to 5. The two scores are added together to get the Gleason score. The higher the score, the greater the chance that the cancer will (or already has) spread.
Based on your PSA level, cancer stage, and Gleason score, your doctor will estimate how likely the cancer is to grow and spread. Because all treatments for cancer can cause side effects, doctors aim to give patients treatments that will cause the fewest side effects while effectively curing the cancer. In some cases, the risk of the cancer getting worse may be relatively small compared with the side effects of treatment. However, when the risk is high that the cancer will grow quickly or recur after treatment, doctors may prescribe aggressive treatment to reduce that risk.
Treatment of Prostate CancerThe effectiveness of treatment depends on how localized the cancer is and whether or how far it has spread in your body. Depending on the stage of your disease and the other indicators discussed above, the characteristics of your tumor, and your age and general health, your doctor will recommend one or more of the following: active surveillance (also called observation, expectant management, or watchful waiting), surgery, radiation therapy, hormone therapy, chemotherapy, or targeted therapy. These options are discussed in the treatment summaries for localized prostate cancer and advanced prostate cancer.
Because some forms of prostate cancer treatment can cause infertility, if you want to father children you may want to discuss sperm banking before treatment begins. Your doctor can help you with this consideration.
Life After Prostate Cancer Treatment After completion of your treatment, you will begin a period called follow-up. During this period, you will visit your doctor at regular intervals. The doctor will perform a physical exam, ask you about how you are feeling, and order tests to make sure that you remain healthy and that any long-term effects of your prostate cancer or its treatment can be addressed. See Taking Care of Follow-Up Care.
NCCN.com Thanks Our Supporters:
ResourcesNCCN Physician Guidelines
NCCN Cancer Resources
NCCN Cancer Answers
Clinical Trials
FAQs
Glossary
Ask Jai
Advice For Caregivers Coming soon, Jai Pausch, widow of Randy Pausch, author of the internationally acclaimed best-selling book, The Last Lecture (see the video here), will share her experience and wisdom as a cancer caregiver. The new monthly column, “Ask Jai,” will offer real-world advice on coping with cancer’s challenges, managing your own life, and helping those you care for.
Have a concern or question to share? Email Jai at askjai@nccn.org.
NCCN Member Institutions
The National Comprehensive Cancer Network (NCCN) is a not-for-profit alliance of 21 of the world’s leading cancer centers. We are dedicated to improving the quality and effectiveness of care provided to people with cancer.