Question: I recently had a prostate biopsy, which showed a small area of cancer in one of the biopsies. 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? - S.L., West Palm Beach, Fla.
Answer: In the case of early prostate cancer such as you have, "active surveillance" is certainly a reasonable approach. The downsides to it are the uncertainty of the prostate cancer's disease course and the anxiety of living with prostate cancer.
Even though treatments like nerve sparing prostate surgery, prostate radiation seeding and freezing have a lower risk of incontinence and impotence than the older 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 Swedish study published in the journal European Urology supports the active surveillance approach. They analyzed 968 men (median age 65.4 years) diagnosed with prostate cancer - 440 of whom agreed to use active surveillance as their treatment strategy. Most of those men had low risk tumors, but there were some men 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 decided to stop active surveillance and get treatment due to cancer anxiety.
That said, for younger patients and/or folks with more advanced cancer than you, active surveillance may not be the best option.
Question: I've been on a low dose (35mg) of Effexor XR for more than 10 years. Before that, I had severe depression and was put on 150 mg/day. It worked, so after a while I decided to try to wean myself off it. The problem is when I try to get off it completely, I get lightheaded and a feeling of electrical sparks in my head. What do you suggest I do - stay on it or push through the horrible withdrawal? –Anonymous, Lilburn, Ga.
Answer: Unlike the traditional "SSRI" antidepressants such as Prozac, Zoloft, Lexapro and Paxil that raise serotonin levels in the brain to improve and stabilize one's mood, Effexor is what's called an "SSNRI", meaning it raises both serotonin and norepinephrine levels in the brain to improve and stabilize one's mood. In theory, it might seem a drug that targets more than one chemical in the brain would be better than the SSRI drugs.
When Effexor and Effexor XR were originally marketed to prescribing physicians, the dual mechanism of action was a part of their marketing strategy. Effexor XR has been an effective drug in the management of depression, but what was downplayed in the sales pitch to doctors is the drug's very short half-life of only 5.5 hours. That compares with Zoloft's half-life of 26 hours and Prozac's half-life of 48-72 hours. It's true Effexor breaks down into an active metabolite with a half-life of 9 hours, but even that is still fairly short. What all that means to someone taking Effexor or Effexor XR is with a short half-life, the drug level in the brain abruptly and dramatically drops if one misses a dose, abruptly tries to stop it or, for a number of folks such as you, just tries to taper off it. Because it has such a short half-life, every other day dosing won't work as a taper.
For those wanting to get off it because they no longer need an antidepressant, if they can't work through the withdrawal symptoms, here's an off-label strategy: Open the capsules and systematically, over weeks/months, remove increasing amounts of the granules from each capsule until such a point where successful weaning off the drug occurs without serious withdrawal side effects.
Dr. Mitchell Hecht is a physician specializing in internal medicine. Send questions to him at: "Ask Dr. H," P.O. Box 767787, Atlanta, GA 30076.