Ask Dr. H: 'Actively watching' prostate cancer

Posted: November 26, 2012

Question: I recently had a prostate biopsy, which showed a small area of cancer. My urologist discussed the option of close surveillance, with periodic biopsies and regular PSA blood testing. I'm 65 years old and otherwise in great health. Do you think it's better to treat the cancer or just watch it?

Answer: In the case of early prostate cancer like you have, "active surveillance" is a reasonable approach.

The downsides are the uncertainty of the disease course and the anxiety of living with prostate cancer. Even though treatments such as nerve-sparing prostate surgery, prostate radiation seeding, and freezing have a lower risk of incontinence and impotence than the traditional radical prostate removal procedure, there's still a risk of causing more harm than if the doctor watched an early prostate cancer closely and intervened as necessary.

A recent study published in the journal European Urology supports the active surveillance approach. It analyzed 968 men (median age 65.4 years) diagnosed with prostate cancer, 440 of whom agreed to active surveillance as their treatment strategy. Most had low-risk tumors, but there were some with intermediate- or high-risk tumors.

Sixty of the 440 subjects who underwent active surveillance eventually died - but only one death was caused by prostate cancer. Sixty-three percent of the men kept using active surveillance for the rest of the follow-up period (up to 15 years). None of the low-risk patients developed metastatic prostate cancer or died from the disease. Four men stopped active surveillance and got treated due to cancer anxiety.

That said, for younger patients and/or men with more advanced cancer than yours, active surveillance may not be the best option.

Q: I've been on a low dose (35-milligram) of Effexor XR for over 10 years. Before that, I had severe depression and was put on 150 milligrams per day. It worked, so after a while I decided to try to wean myself off it. The problem is that when I try to get off it completely, I get light-headed and a feeling of electrical sparks in my head. What do you suggest I do - stay on it or push through the horrible withdrawal?

A: Unlike the traditional "SSRI" antidepressants such as Prozac, Zoloft, Lexapro and Paxil, which raise serotonin levels in the brain to improve and stabilize mood, Effexor is what's called an "SSNRI" - it increases both serotonin and norepinephrine.

In theory, it might seem that a drug that targets more than one brain chemical would be better, and the dual mechanism was part of the original strategy for marketing Effexor and Effexor XR to physicians. Effexor XR has been an effective drug in the management of depression, but what was downplayed in the sales pitch to doctors is the medication's short half-life - only 5.5 hours, vs. Zoloft's half-life of 26 hours and Prozac's 48 to 72 hours. (Effexor breaks down into an active metabolite with a half-life of nine hours, but even that is short.)

What this all means is that the drug level in the brain drops immediately and dramatically if someone misses a single dose of Effexor or Effexor XR, abruptly tries to stop it - or, for many people like you, simply tries to taper off it. Every-other-day dosing won't work.

Here's an off-label strategy for people who no longer need an antidepressant but can't work through Effexor's withdrawal symptoms: Open the capsules and systematically, over weeks or months, remove increasing amounts of the granules from each until the serious withdrawal side effects are gone.

Mitchell Hecht is a physician specializing in internal medicine. Send questions to him at: "Ask Dr. H," Box 767787, Atlanta, Ga. 30076. Due to the large volume of mail received, personal replies are not possible.

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