what would you do if you were the urologist and your father was the patient?

if you can walk with kings and not lose the common touch
Read the following comment and then my thoughts after it.  Being a doctor is a lot like a person gambling with someone else’s money. Read the comment and then I’ll explain.
October 08, 2010, 11:28:15 AM | Dean Hubbard

My physician and urologist recommended a biopsy when my score hit a 5 at age 55. Nothing there. Later, when my score was a 6 another biopsy was recommended. Nothing there…again. Once I had a 9.9 and two months later it was a 6. My latest score, the eighth since 2006, is a 7.3. I’m 61 yrs. old now and my prostate is sized “…between 40 and 60″. Oddly, neither of my previous two urologist EVER mentioned that a bigger prostate will produce more enzyme. So, why was I being unnecessarily frightened by the urologists while being compared to those men with a prostate size around 15g? No DRE has ever inidicated any nodules in my prostate. The PSA test is not an indication of anything other than the presence of the enzyme. A fried seafood dinner and sex the night before can elevate the score. (Unfortunately, I was not told that by any doctor.) I’m sorry, but after my second biopsy I couldn’t help but remember what caught my eye on the way out of the urologist’s office: his shiny black Porsche Carrera Turbo. After my latest score my current urologist’s nurse (by phone) has urged me in strongly worded suggestions to consider “talking to the doctors” at my earliest convenience. I’ve heard this story before and patients like myself are tired of hearing the alarm, paying the money, and suffering the biopsies, simply because the PSA chemoluminescence indicates something above a 4. Urologists need to stop frightening us by using an incredibly fallible test as a basis for doing so. Urologists need to donate a portion of their income and book sales to research that can find a better test.

My thoughts…

  • Except for the penis…size doesn’t matter. Whether a prostate is small or big it can still harbor prostate cancer. One can reason that, “my PSA is high because I have a big prostate” but the problem remains… a high PSA. So what to do? You can ignore it, repeat it, or do  biopsy. I tell folks with a high PSA, we usually repeat the value at least once because of known variations, that you  really do need to  do the biopsy at least once to  be sure there is no  cancer. Otherwise you  are  just “mentally masturbating” about whether the PSA means cancer or not.
  • Here’s the problem if you are the urologist.  Think of Will Roger’s saying, “to know or feel what a fella’s thinking, go around behind him and look out at what he’s looking at.” So you are doctor and your patient has a high PSA.  He is there for you to tell  him if he  has cancer or not. What to do? There is only one way…a biopsy. Okay…as in the situation  above, your patient returns at some point and the PSA  has gone up. Only three options, repeat the value at some point in the future, ignore  it, or do a biopsy. Hint: If you don’t do a biopsy and the patient returns a  year  later and the PSA is higher again  and you  do a biopsy  then  and it’s positive for cancer…well you are going to have a very unhappy patient and family wondering why you waited a year to make the diagnosis. If that patient has asymptomatic bone disease for metastasis (uncommon but trust me it happens) then you are at  risk for a law-suit. So in the comment above I agree with all the issues and also  feel the author is intelligent. I love that word chemolumenesicencesesssxz, but the fact remains that each  time the PSA goes up and there has been a period of time that passes, a  new decision has to made. You can’t base  a  negative biopsy four  years ago to lend  credence to  not acting on an elevated PSA today. “I’ll gladly pay you Tuesday for a hamburger today.”
  • I have a friend whose father I see. He is 78 and has a PSA of 16. I had biopsied him two times over 5 years, each negative. He comes in about four months ago and now his PSA is 19. I say, ” we have two options…one ignore the change and repeat it in few  months or so, or two repeat the biopsy.” As the doctor, it is more definitive  to do  the biopsy. His son is a friend of mine, what if  the man has cancer and I have missed it with the previous biopsies. (You only take 12 cores, so a prostate biopsy probably only samples less than 1% of the gland.) It been a  few years since the last biopsy so I lean on him to repeat the biopsy.(Ps….you notice I have not mentioned money nor  did money have anything to do with  my decision-making process.) We do the biopsy and one core  of twelve comes back  positive. Now here is the kicker. It was Gleason’s 8. That’s a bad actor. That is not  an incidental cancer that old people  get anyway. So, I send him over to the radiation therapist, and he is impressed by the Gleason score and in turn recommends radioactive seeds.
  • If you are the urologist and over your career you  have seen  things happen like, a small gland and a low PSA that had an aggressive cancer, or a big gland and low PSA and bad cancer, or normal gland and  only a slight change in  the velocity of the PSA and you find a bad cancer…and on and on….begin  to be wary  of the PSA and you do become a bit defensive. What I do is lay it out for the patient,  I try to go over the scenario’s and then  the patient decides.
  • Try this question and it is one that I have used many times….” Mr. Smith,  if you had prostate cancer would you want to know?” Think of it that way.  The  only way to know is the biopsy.  
  • “Mr. Smith, do  you want to fish or cut  bait. We are gambling with your money.”
  • In the above comment, I don’t have big problem with the fact that biopsies were done or that they were negative. There does appear to be a problem  with communication and there is never an excuse for that particularly if you have  an intelligent and motivated patient  as this.
  • Final thought…..regarding the comment and the history of this patient….we still don’t know if he cancer or not and if the PSA is on the basis of an  undiagnosed cancer or an elevated PSA because of an enlarged prostate. My feeling is that he does not have prostate cancer. If he  were my patient, and the PSA goes up again, I might recommend a  Free PSA and see if the free  portion low  or high. In my hands if the free  portion is low, I’d recommend another biopsy. I’d document that I recommended another biopsy. And  then, the patient decides, gets  a second opinion or whatever. It’s tricky….I’ve been there done that.”

Dirty little secret: you still could have undiagnosed prostate cancer and it could be an aggressive form. Unlikely yes….but remember….we’re gambling with your money. In many ways it all ends up with  what a patient can “live with.”

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