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 to impact HRPC prognosis, but it does increase the risk of dying younger from other causes, such as cardiovascular disease. Keeping other disease states under control, as much as possible, and maintaining general health through exercise and proper diet make a lot of sense.
Pain Men with HRPC and different pain levels tend to have different prognoses. The worse the pain caused by the cancer itself, the worse the prognosis or the more serious the situation. This makes sense because tumors that have grown large enough to cause pain are more troubling than smaller tumors not causing pain. Pain caused by other chronic conditions, such as arthritis, does not play a role in this consideration.
Performance Status Performance status is a scale that attempts to quantify the general well-being or quality of life of a patient. Healthcare professionals use the scale to determine whether someone should receive chemotherapy treatment, whether a dosage change is needed, or if therapy should even be continued for a particular patient. Two commonly used scales are the ECOG (Eastern Cooperative Oncology Group, one of the largest clinical cancer research organizations in the United States) test and the Karnofsky Performance Status test (named for Dr. David A. Karnofsky). A brief description of each follows. Overall, a poor performance status indicates a worse prognosis as compared to someone with a better performance status.
ECOG Performance Status
Numerous clinical trials require an ECOG performance status of 0 to 2 in order to be allowed to participate in clinical trials. Scores of 3 or 4 usually do not receive chemotherapy because the possibility of benefit is outweighed by the potential of negative side effects (of course, there are exceptions).
0 Asymptomatic (fully active, no restrictions)
1 Symptomatic and fully able to walk (can perform light work, such as household or office tasks, but cannot do strenuous activity)
2 Symptomatic and spends less than 50 percent of time in bed (can walk and provide self-care, but unable to do work activities)
3 Symptomatic and spends more than 50 percent of time in bed or chair (not bedbound, capable of limited self-care)
4 Bedbound (cannot provide for self-care, completely confined to bed or chair)
Karnofsky Performance Status
Can be expressed as a range (90–100) or a specific number (92).