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Archive for the ‘Active surveillance’ Category

if you point your finger at someone...there are three pointing back at you....or seeing sawdust in another's eye when there is a log in your own

The above illustration is from “The Decision” now the number one book on Kindle for the subject of prostate cancer on amazon.com

“But I don’t have any voiding symptoms doc.”

“A little knowledge is a dangerous thing.”

Podbean podcast prostate diaries…….minute on the subject and this silly and trite objection

An interesting question on Podbean

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love has no eyes....love is so unwise.....JT

A podcast in response to a question: Should I have a biopsy for an elevated PSA if I have a bladder infection?

Anyway…this podcast is a bit weird. I did it with a free recording software and a microphone that cost 8 dollars from Wal-Mart. So what do you expect? What in the world is that sound in the middle of my podcast? So…the podcast is a work in progress but may server as a medium to further elucidate the nuances that are peculiar to that “old chestnut’ prostate cancer. Pss… Do you recognize the intro and the jazz guy used for the intro? My kids called it, ” hot tub music” because that’s what I put on when they were little and we’d play in the hot tub before dinner. If I hit it big…they’ll come after me for copyright encroachment.

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if kisses were all the joys in bed, one woman another would wed....shakespear

Prostate cancer doesn’t mean no sex life

April 7 2011 at 11:15am
By Anna Hodgekiss

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iol life april 7 Andrew Lloyd Webber picREUTERS

Composer Andrew Lloyd Webber

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Composer Andrew Lloyd Webber last week revealed he’d been left impotent following prostate cancer surgery. He is one of 37,000 men who are diagnosed with the disease each year in the UK.

There are various treatment options available, but which is best and what are the implications for your sex life?

“There are three considerations when it comes to treatment,” says David Neal, professor of surgical oncology at Addenbrooke’s Hospital in Cambridge. “We need to remove the cancer, prevent urinary incontinence and preserve sexual function – and the majority of patients agree this is the order of importance.

“However, the key indicator of what your sex life will be after the operation is what it was like before. Remember also that sexual function may begin to wane naturally once a man reaches his 50s and 60s.”

John Anderson, vice president of the British Association of Urological Surgeons, agrees. “It’s important to look at the demographic of many men who get prostate cancer. It is typically a disease of older men and, in these men, erectile function is not always at its best anyway.

“Then there is the tumour itself; your risk of impotence depends on the extent of the disease, which dictates how much treatment you will need.”

Your choice of surgeon is also “critically important – more so than the technique you undergo,” says Professor Neal. “You really want a surgeon who performs at least 80 to 100 procedures a year for your best chance of success on all fronts.”

Professor Roger Kirby, director of The Prostate Centre in London, says: “If the cancer was localised and the nerves were preserved, there is a good chance of regaining some sexual function.

“Many men find that things slowly begin to improve months, even years afterwards, as the nerves regrow.”

Here, with the help of the country’s leading prostate experts, we examine the pros and cons of each treatment and their possible effect on sex life.

ACTIVE SURVEILLANCE

The patient receives no treatment but is closely monitored every three to six months in case the cancer becomes more aggressive. “Many prostate cancers are slow-growing; we are getting much better at sorting the aggressive tumours from the slower growing ones,” explains Professor Kirby.

SUITABLE FOR: Low-risk, early-stage prostate cancer that is contained within the prostate. Patients with a Gleason score of six or less.

This measures the aggressiveness of the cancer from a tissue sample. A score of six and under is the least aggressive cancer; seven indicates a middle-ranking cancer; eight and above is the most aggressive.

WHAT IT INVOLVES: Regular hospital tests. These include a prostate specific antigen test to detect a protein linked to prostate cancer (rising levels could indicate the cancer has become more serious), digital rectal examinations, magnetic resonance imaging (MRI) scanning and biopsies.

PROS: “It can be ideal for those men with low-risk prostate cancer who are happy to defer treatment unless absolutely necessary,” says Mr Anderson.

“And more and more men are opting for this over treatment,” says Professor Kirby. “Of the 37,000 men diagnosed with the disease each year, only around a third will die from it.”

CONS: Some men may become anxious about their cancer changing. Occasionally, the cancer may change or grow faster than expected.

EFFECT ON SEX LIFE: The best outcome of all the options – there is no risk of damage to the nerves that assist sexual function. “The problem is, the nerves that enable a man to become aroused are very close to the prostate – this is why surgery can cause problems,” explains Professor Neal.

OPEN RADICAL PROSTATECTOMY

The most common type of surgery to remove the prostate gland and some surrounding tissue.

SUITABLE FOR: Cancers with a Gleason score of six and above which have not spread beyond the gland, with the patient being relatively fit and healthy.

WHAT IT INVOLVES: A two to three-hour operation where the prostate is removed following a 6-7cm incision in the lower abdomen under general anaesthetic.

PROS: “The aim is to remove the cancer completely,” says Mr Anderson. “If this is successful, and the cancer has not spread outside the prostate, it will return you to normal life expectancy.”

CONS: Overnight stay in hospital with greater risk of bleeding and a longer recovery period.

EFFECT ON SEX LIFE: A quarter to a third of men will lose sexual function due to damage to the surrounding nerves and small blood vessels responsible for erections. “In men who have good function beforehand, there is on average a 66 to 75 percent chance they will be able to perform afterwards,” says Professor Neal. “But remember that it takes a good 12 to 15 months to recover from prostate surgery. Pretty much everyone is impotent straight after.”

“It’s fair to say that a man in his 50s has a better chance of retaining function than a man in his 70s,” adds Professor David Gillatt, director of the Bristol Urological Institute.

Nerve-sparing prostate surgery is where the surgeon tries to avoid damaging the two nearby bundles of nerves that control erections, explains Mr Anderson. It may be possible if the cancer has not spread too far. Studies show that for every ten men with both nerve bundles spared, between three and eight regained erections.

KEYHOLE RADICAL PROSTATECTOMY

The prostate gland is removed through tiny cuts in the abdomen rather than one large one. This is the treatment Andrew Lloyd Webber had.

SUITABLE FOR: A similar group to open surgery, but is becoming the preferred method for many surgeons.

WHAT IT INVOLVES: There are two methods – by hand or using a Da Vinci robot (a relatively new technique). The surgeon makes five or six small cuts in the abdomen and inserts a camera through a tube that magnifies everything ten-fold.

Tiny instruments go through the other holes and the operation takes two to three hours. In robotic surgery, the camera used is 3D and high-definition, explains Professor Prokar Dasgupta, of Guys and St ThomasÕ Hospital, who pioneered robotic surgery in the UK eight years ago.

PROS: “As with many types of keyhole surgery, there is a quicker recovery time, less pain, bleeding and scarring,” says Professor Kirby (who has performed more than 800 robotic removals). ÔBecause the structures can be seen so much more clearly, robotic surgery should be more effective than open prostatectomy, but this needs confirmation from long-term studies.

“I believe it’s the best way to treat prostate cancer and have abandoned open surgery because of this.”

Professor Dasgupta adds: “The cancer control is good and we can often spare the nerves responsible for continence.”

CONS: Similar long-term risks of impotence and incontinence problems with manual keyhole as for open surgery but robotic operations, with an experienced surgeon, may dramatically reduce this.

EFFECT ON SEX LIFE: “We find that many younger patients recover their potency very quickly after robotic surgery,” says Professor Dasgupta.

EXTERNAL BEAM RADIATION

High-energy X-ray beams are directed at the prostate gland to eradicate the cancer cells by stopping them from dividing and growing.

SUITABLE FOR: Older patients and those with more aggressive locally advanced cancer with a Gleason score of seven or above; patients health conditions that make them unfit for surgery.

WHAT IT INVOLVES: The most common type is 3D conformal radiotherapy. This directs beams to fit the size and shape of the prostate while helping to avoid damaging the healthy tissue around the prostate.

The new intensity-modulated radiotherapy can deliver different doses of radiation, meaning less risk to surrounding tissue.

PROS: Painless and requires neither general anaesthetic nor overnight hospital stays.

CONS: Daily trips to hospital for seven weeks. “There is always the danger with leaving the prostate inside the body that some residual cancer may remain,” says Professor Kirby. “Radiotherapy can also cause an irritated bladder and bowel – many patients complain they feel the urge to ‘go’ all the time,” explains Professor Gillatt.

EFFECT ON SEX LIFE: Sexual dysfunction rate is the same as after surgery: between a quarter and a third of men will be impotent. “However, with surgery the body recovers over time,” says Professor Neal, “whereas radiation damage can continue occurring for two to three years after the treatment.”

BRACHYTHERAPY

Tiny radioactive seeds – the size of a grain of rice – implanted in the prostate emit radiation to the surrounding tissue, destroying cancer.

SUITABLE FOR: Men with smaller and localised tumours that are low-medium risk (Gleason grade seven). Not suitable for those with large prostates or men with urinary problems, as it will make the problem worse. High-dose brachytherapy may be offered for higher risk cancers, but this is not widely available.

WHAT IT INVOLVES: The seeds are inserted via needles close to the tumour, with an epidural or under sedation. (They remain in the body permanently, becoming inactive after eight to ten months.)

PROS: “Treatment is rapid, taking just two days,” explains Professor Neal.

Because the radiation doesnÕt travel very far in the body, the healthy tissue around the prostate gland gets a much smaller dose of radiation and so may cause less damage to bladder and urethra resulting in fewer incontinence problems.

CONS: “It can cause problems with urination if the prostate swells – a common side-effect of this treatment,” explains Professor Gillatt. (The prostate surrounds the urethra, the tube that delivers urine out of the body, like a doughnut.)

EFFECT ON SEX LIFE: “Some doctors say this has a lower risk of impotence, but the evidence is not there,” says Professor Neal.

And, adds Professor Gillatt, just like conventional radiotherapy, the effects on sexual function may take time to appear.

HIGH INTENSITY FOCUSED ULTRASOUND

A relatively new treatment that heats and destroys cancer cells in the prostate.

SUITABLE FOR: A minority of men for whom loss of potency is their paramount concern. May also suit men unhappy with active surveillance, or older men unsuitable for surgery.

WHAT IT INVOLVES: A probe inserted into the rectum passes ultrasound waves through the wall of the back passage and into prostate gland. The ultrasound energy causes the prostate cells to heat up, destroying both the healthy and cancerous cells.

PROS: Can focus on certain parts of the prostate gland where the cancer is, potentially avoiding damage to other nearby organs and nerves responsible for sexual function. No scars, and can be performed as a day case. If unsuccessful, it is still possible to undergo surgery or radiotherapy at a later stage.

CONS: Widely considered an experimental treatment Ñ no long-term results have been published yet, says Mr Anderson. Professor Neal adds: ÔThe concern with HIFU is that it focuses a beam on the prostate and burns selected areas where the cancer is. But there may be other areas of cancer in the prostate that do not appear on an MRI scan and therefore may not be treated.Õ

EFFECT ON SEX LIFE: More evidence is needed.

HORMONE TREATMENT

Controls testosterone, the male hormone that fuels prostate cancer cell growth.

SUITABLE FOR: The gold standard for patients with advanced prostate cancer that has spread beyond the gland and is untreatable using surgery.

WHAT IT INVOLVES: Drugs called LHRH analogues, such as Zoladex, are given as an injection every one or three months, depending on the dose. There are also anti-androgen tablets such as Casodex, taken daily that stop testosterone from reaching the cancer cells.

PROS: While not a cure, hormone therapy can be a lifelong treatment. It slows tumour growth, reduces symptoms and shrinks the cancer. For this reason it’s also commonly used before radiotherapy and sometimes afterwards to help improve the effects of treatment.

CONS: Testosterone is important for bone health; by reducing it, this raises the risk of osteoporosis.

EFFECT ON SEX LIFE: “Treatments such as LHRH analogues destroy your sex drive,” says Professor Kirby. “They lower libido because they lower testosterone, the driving force behind it.” However, taking anti-androgen tablets may allow a man to preserve his hormone levels – or at least stop his libido being quite so battered – as they don’t actually stop testosterone being produced, says Mr Anderson. – Daily Mail

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CNN visits Dr. John McHugh’s Urology practice for a Health Minute on March Madness and Vasectomies. The scene with the patient pretending that he is hurting actually occured minutes after the vasectomy. Vasectomies are customarily performed on a Friday so that the patient has the weekend to recover prior to returning to work on Monday. So, it stands to reason that having a vasectomy prior to a big sporting event, regardless of the sport, is a good time to “tie the knot” the second time.

CNN’s Health Minute Comes to Northeast Georgia Urological Associates for Vasectomy Madness/March Madness- Click here to watch!

Having a vasectomy a round about form of “Prostate cancer screening?”

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it's not the size of the dog in the fight...it's the size of the fight in the dog....

So I am out at the lake where the above picture was taken and I have DSL and a laptop I recently purchased to leave out here and I was assured by the computer guy that it  was fully loaded with Microsoft Word. So I do the blog stuff, walk my dogs to the steps in front of our dock, throw some sticks, was some sheets, gather trash and then sit down to begin my “Best Christmas Ever” book for this Christmas to give out to patients and friends. I mean, I have the story in my head and I worked on the beginning of it in my head on the “Jessie Jewel” steps at the lake and was excited about sitting down and starting the story. About me, of course, and in first person. John Irwin, author of “The Prayer for Owen Meany” said that first person gave the author more emotion and feeling. I need that for this story.

Anyway, the damn laptop has a starter version of Word 2010 and won’t let me open the damn thing. I’ll have to take the laptop to the computer guy that comes by my office and have him install or for him to condescending say to me, ” Oh, you just push this button,” or ” press this key, the program you need is right here. You could have used it all along.” I don’t know the button and now can’t do what I wanted to do this afternoon. Then I got Mr. Huberts comment: I have a question for him and the Squarf’s of the world. It is a very simple question and I am sure there will be a simple answer.

Missures….Squarf and Herbert:

You two are urologists ” informed and enlightened as you are” and I am your younger brother. For better or worse my family doctor has been getting PSAs on me and this is what’s going on. (This is my true story)

Your little brother is married, employed, has three children, healthy and has serial PSAs that have gone from low threes to 5.4. Your little brother (for better or worse ) had a biopsy and it showed 4 of 16 positive and there were elements of Gleason’s 7. You know your little brother to be a bit anxious about things and not only that his wife particularly is. You detect it in your conversations with him. His children are all in high school save one, who has finished college, married and pregnant.

Here’s the question: What would be your advice to me? A word of caution…if you list or ramble on about numbers an percentages remember I am your little brother and I am counting on you. Also remember one in a hundred is 100% if it’s you. I am not a number, a statistic, a public health funding issue, I am young, vibrant and want what is best for me and my family.

Now you are the doctor….what do you two recommend?….not for the masses but your little brother.

I appreciate you both…this fun to me…ya’ll “add flavor to the soup” that must be considered by the newly diagnosed prostate cancer patient in making “his” decision.  Pssssssssss—–when you use emotional words like “dug out prostate tissue” or “Dr. Doom” you betray the origins of your opinions.

Nostradamus? You both referenced him. Predictions that came true but because of laxity of interpretation and the “watered down” clarity of time influenced by those hoping to prove his assertions correct.

You are correct you cannot know will happen to your little brother if he does nothing (remember his age) or if he does something. On which side of erring (making the wrong decision) do you two want to be on? Let me be clear…I am not saying you are wrong, but what do you tell your little brother to do?  Will you tell him what to do or will you give him options? If you give him options are you being true to your beliefs?   Have fun with it…no emotion here. I lay out the facts and my patients make the decision they feel is best for them…just as you two did.

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life is a lot like playing cards-it's not about the hand you are given, it's about how you play the cards you're dealt

The “art of getting away with it” is a favorite medical saying of mine. If I remove a ureteral stone and don’t place a stent and risk extravasation of urine into the patient’s retroperitoneum and the patient does just fine….what does that mean? Does it mean that I was brilliant, used seasoned medical judgement, or did I just “gamble with the patient’s money” and just “got away with it?” Did Mr. S just “get away with it?”

Submitted to Prostate Diaries on 2011/03/26 at 10:53 pm

I am the above referenced Squarf. My health is perfect, my urologicals are so splendid that I shall leave them to the National Bureau of Standards when I keel over. My Dr. Doom will die of sclerosis of his personality before anything takes me down. Prostate cancer is the biggest boondoggle in the history of medicine. You may quote me.
-Lorenzo Q. Squarf, Flamekeeper of Western Civilization

Used Cars and Mr. Squarf

Mr. Squarf-Fool or Guru?

After I wrote my book I began to explore fun ways to promote it using social media. In my twenty years or so of practicing urology I had never gone on the internet to search anything related to urology, much less prostate cancer. I have a subscription to the Journal of Urology and that is my usual resource for researching something. I have found over the years that the articles there often legitimize something that I have already been doing for years. An example would be the transobturator sling. We had been doing them for years with very nice results for stress incontinence in women and then I see an article saying that slings are effective.

So when I search around the internet I was surprised to find so much angst out there about urologists (money hungry will only operated and make you leak urine and impotent), the PSA how it has ruined patients lives and made the drug companies rich (Mr. Richard Albin), and people who are so angry about doctors, PSA’s, prostate biopsies that they “threw out the baby with the bath water” and totally went “naked.” There is an interview with the head guy of the American Cancer Society and he said something to the effect that he disagreed with prostate screening and then asked if he’d had a PSA , he said no and that ” I won’t be getting one.” Nihilism comes to mind.

Now to Mr. Squarf…I like him but I don’t know him. He’d be a caricature in my book on the types of prostate patients and how “who they are” determines which treatment, or lack thereof, they choose. You really need to read his thoughts on PSAs, urologists, and prostate biopsies. I did re read his stuff, but as I remember he had an elevated PSA and elected to not follow the value closely or to have a prostate biopsy. (He was not going to let the system us him for their financial gain or play into a urologist’s sadochistic tests. The little knowledge is a dangerous thing mixed with the clever by half patient. That’s going to be a tough caricature for my wife to draw. )

  • The most common symptom of prostate cancer is…no symptoms. So Mr. Squarf recommendation to wait until symptoms I would disagree with rather strongly.
  • Repeat PSA’s with a rectal exam and pursue a biopsy if it changes with time…is reasonable.
  • Mr. Squarf story is what we call in the business “an anecdotal account.” We know that about 20% of elevated PSA’s result in the diagnosis. Not all of those diagnosed need to be treated, some do. That’s where research and “who are you factors” come in. At age 65 a lot of what Mr. Squarf recommends makes sense. It might not to a 60 year old in better health.
  • Mr. Squarf “got a way with it” his PSA was high and elected to do nothing and he did not have prostate cancer. He was the 80%.  Good for him…but to advise that all do what he did and a say, “don’t let them biopsy you unless you have symptoms” may be harmful to certain patients.
  • His decision seems to driven more by angst at the system than a smart medical choice-reminds me of Otis Brawley….making a medical stance to make a point.
  • Mr. Squarf was I wrong to have a biopsy and then have my prostate removed. I was 52, 3 of 16 positive, and there were elements of Gleason’s 7. Was I foolish? Was I duped by my self? What was going to be the pathologic future of my cancer? At what point does an elevated PSA associated with known prostate cancer change from being local or confined to the prostate and the point when it moves to a lymph node (metastasize).
  • Mr Albin’s father presented with symptoms, just like you suggested he do, he could not void and had prostate cancer in his bones. He died about a year later. Is this perfect scenario that your recommendations allude to?
  • Did Frank Zappa play it just right? He waited for symptoms to occur he. He died about three years after diagnosis at age 54 or so.
  • Do you feel that the American Urological Assoc recommendations regarding PSAs and screening are driven solely by the love of money?
  • Do you what would have happen to me if I had done what you did? I mean…do you know for sure?

So….these are just questions. That’s all, just questions. Mr. Squarf made a decision, based on research and suspicion of the medical community, and he was right. He gambled with his money and ” he got away with it.”

I love his irreverence, humor and those big words. And now he’s kinda rubbing his decision in our faces….be careful Mr. Squarf….you just might influence someone to do what you did and he was not the 80% but the 20%. He also may be that prostate cancer patient (and I have had many, including a close friend of mine) in whom the gland remained normal, the elevated PSA did not change and yet a biopsy showed every core of the prostate positive for prostate cancer. He was 58 or so and I think that finding his cancer and treating it made a difference. (This is anecdotal as well.)

Mr. S…..great to hear from you and I eagerly await a concise rebuttal of sorts in a mildly vociferous fashion.

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you learn more from failure than from success

A Nice Article and Issues Surrounding  Proton Therapy

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