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from Medscape.com

BOSTON — Physicians who routinely treat prostate cancer are “very likely” to undergo PSA screening themselves or recommend it to immediate family members, concludes a survey-based study presented here at the American Urological Association (AUA) 2017 Annual Meeting.

In total, 784 (90%) of the 869 physician respondents endorsed past or future screening for themselves or for relatives.

The survey respondents were mostly urologists (83%) and mostly came from North America (68%), as well as Central and South America, Europe, Australia, and New Zealand.

Less overwhelmingly, only 61% of the 807 male respondents had personally undergone PSA screening. However, 94% of the “screen eligible” men said they had taken a PSA test, clarified lead study author Christopher Wallis, MD, from the University of Toronto, Ontario, Canada.

Awkwardly, Dr Wallis did not know the age the AUA recommends most men start screening, when asked by a reporter. He guessed 50 years of age. “Fifty-five,” quietly said Stacy Loeb, MD, from New York University, New York City, who moderated the press conference.

Dr Wallis pointed out to Medscape Medical News that the survey is international and that, although the AUA recommends screening from age 55 to 69, the NCCN recommends screening from age 45 to 75, and the EAU recommends screening from 50 until life expectancy is less than 10 to 15 years.

Dr Loeb was loud and clear about the new results: “We can see that the doctors who manage prostate cancer really do practice what they preach, and choose PSA screening for themselves,” she said in a meeting press statement.

In the survey, 82% of the 807 male physicians also said they planned to have a PSA test in the future.

The women were less enthusiastic: Only 69% of the 62 female physicians had recommended PSA testing to immediate family members.

But the study has a methodological limitation: it contains exclusively self-reported behavior. “We don’t know if the men who said they got PSA testing actually got PSA testing,” Dr Wallis admitted.

Furthermore, “these results may be unreliable,” Dr Wallis told reporters.

“We don’t know if the men who said they got PSA testing actually got PSA testing,” Dr. Christopher Wallis added.

 He explained that physicians have been shown in a previous study to recommend different treatments than they would choose for themselves ( Arch Intern Med. 2011;171:630-634). The study was widely reported at the time, including by Medscape Medical News.

There is also a “discrepancy” between what physicians may recommend to one individual patient and what they recommend in general for a population of patients, according to other research, Dr Wallis said, citing other research.

 He said his team employed the “physician surrogate method” to “try and get around these issues.” Their methodology called for posing both direct and hypothetical questions to allow for a fuller range of responses. This method has, for example, been used to interview physicians about lung cancer preferences, he explained.

In the new survey, the male respondents were directly asked: “Have you been screened, and will you be screened?” If a man was not of screening age, the question was, “Do you plan to get screened?”

Women respondents were asked what they recommended their first-degree relatives (husbands, fathers, brothers, etc) do about PSA testing.

The study has limitations in addition to self-reporting. First, the authors do not know the response rate. “The organizations that distributed the survey wouldn’t tell us,” said Dr Wallis.

Second, the respondents were predominantly urologists. The responses may have differed with more oncologists, he suggested.

The purpose of the survey was to examine what motivates the recommendation for PSA testing from specialists.

“You could say that, in theory…a specialist may recommend screening to identify a cancer because that drives patients to them,” which is a financial motivation, but the results suggest these professionals are motivated instead by their trust in the PSA test, added Dr Wallis.

Finally, the survey also asked physicians whether they were diagnosed with prostate cancer and, if so, what treatment they chose.

Thirty men responded affirmatively: they had prostate cancer and had been treated. Similarly, 16 women responded affirmatively, speaking on behalf of relatives they had advised.

Specialists tended to get treated by their fellow specialists: “Urologists choose surgery, radiation oncologists choose radiation,” said Dr Wallis.

That is, 64% of the responding urologists received a radical prostatectomy and 83% of radiation oncologists underwent radiation therapy. There was a significant correlation between specialty and treatment (P = .001).

These treatment preferences are concordant with other research, emphasized Dr Wallis. That concordance, he said, might bode well for the accuracy of the PSA portion of the survey.

“Perhaps people are responding in a way that is reliable for our other question,” he said hopefully.

American Urological Association (AUA) 2017 Annual Meeting: Abstract PD07-07. Presented May 12, 2017.

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

For more from Medscape Oncology, follow us on Twitter: @MedscapeOnc

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He who ceases to be a friend, never was one. "I am hard on friends." jm

This was a comment/question a few days ago….this issue is confusing  but I think I can simplify it-here goes.

  • The ongoing debate about the PSA has to do with pretreatment decision-making. The PSA is often times elevated before the diagnosis of prostate cancer is made for many reasons other than prostate cancer. So some want to “throw the baby out with the bath water.” If you come into my office and you are referred to me for an elevated PSA (anything higher than 4) a couple of things could happen. I might repeat it, I might give an antibiotic and repeat the PSA several weeks later, or if on rectal exam there is an abnormality-I would recommend a biopsy then without repeating the PSA (the rectal exam trumps the PSA if the prostate feels abnormal.)
  • If the PSA is elevated pre diagnosis (by this I mean at this point we don’t know if there is cancer or not) I put a lot of weight on a strong family history of prostate cancer. So if you show up in my office with an elevated PSA and your father and brother have had prostate cancer…I’ll recommend a biopsy.
  • So before the diagnosis of prostate cancer in that patient with a high PSA…if there is no family history and the rectal exam is normal..it is a good thing to “drag your feet a bit” and repeat the value after some time or antibiotics and if still elevated…proceed to biopsy.
  • The PSA is variable in the man who is pre treatment and pre diagnosis, and is one of many arrows in the doctor’s quiver.
  • Obviously if the patient is in bad health, old and the gland is normal to exam and there is an elevated PSA from a year ago and it is about the same as the one you have now…that’s a reason to defer a biopsy.
  • The reason I am an advocate of a PSA at 40…it serves as baseline. We are less excited about a patient whose PSA may be elevated but has been that way for years, than the guy whose baseline for years has been 4 and now it is 7. (Vel0city change.)

Where the PSA is variable but helpful pre treatment and pre diagnosis…it is an excellent marker post treatment..i.e “you can take it to the bank.”

  • If you have had the prostate removed the PSA should go to almost zero… with the ultrasensitive method it should be .02 or so.
  • If after remove the value goes to near zero, it should stay there.
  • If after removal the value goes to .02 and then begins to rise over time…that is evidence of recurrence.
  • How fast it begins to rise (doubling time) is an important prognostic factor.
  • I tell patients this: “It’s best when the PSA goes to zero and stays there. The next best thing is that if it does begin to rise, that it rises very slowly.)
  • For radiation, and things like cryo, HIFU, nanoknife, proton….the PSA usually doesn’t go near zero. It will decline usually to .5 or less. This is called the nadir…and for these treatments if PSA goes to this level and stays there or less…it is considered a cure.
  • If the PSA goes up following these treatments and the trend continues…that represents a recurrence of disease.
  • There is an exception in that radioactive seeds often times cause a PSA bump that occurs around 18 months and then will go back down. It’s tricky time but during that interval the PSA is repeated until it either goes back down or continues to rise….confirming either the bump or recurrence.
  • So…the PSA is a very dependable post treatment tool. The time from the treatment and rate of change give an indication of how aggressive the prostate cancer is and whether it will metastasize.

Finally…When the PSA is really high….if normal is 4  and the patient’s   PSA is say…over 40. (It can be in the hundreds.)

  • If a man presents with a PSA over 40  and there is no other reason for it to be elevated (prostatitis) it is very likely that there is prostate cancer, an abnormal exam, and metastatic disease.
  • If one has been treated for prostate cancer and the cancer has come back and the PSA is now say…10. If that patient is treated with hormonal therapy…in the majority of cases the PSA will go to zero. In this case the PSA is a very valuable test for determining if hormonal therapy is working and when it is not.
  • When PSA continues going up on hormonal therapy, this is a bad prognostic sign. This is called “hormone refractory” and it is usually when the medical oncologist gets involved. This is also where the newer drugs that are so expensive will come into play. (Provenge)

Summary on the PSA test

  1. Pre diagnosis and treatment–helpful but variable—part of the decision-making process but not a stand alone type test.
  2. Post diagnosis and treatment–a very reliable, helpful test to help assess both response to treatment and the recurrence of disease.
  3. In case of recurrence, it is very reliable and valuable in determining if hormone therapy is working , if hormone therapy isn’t working , in the timing of medical oncological referral by the urologist.

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Rush Limbaugh weighs in on the Breast vs. Prostate debate

the prostate and prostate cancer….the rodney dangerfield of cancers and organs

June 26, 2010 by John McHugh M.D. | Edit

 
budding urologist with incontinence-author circa 1959
 
 

Five reasons the prostate is the “Rodney Dangerfield” of organs…it gets no respect.

“I’m not a sexy guy. I went to a hooker. I dropped my pants. She dropped her price.”- R.D.

The reason why the prostate doesn’t get any respect has a little to do with the very nature of the organ and its disease and a little to do with the mindset of the male.  The perfect storm which is a gland that the male can’t see or feel and a cancer that doesn’t cause symptoms until it is too late is the reason for the tragedy of over 25,000 deaths a year in the United States a year. Look at the following reasons and see if  you see  yourself or that of a loved one who isn’t guilty as well.

  • Unlike a women’s breast that gets all the attention an organ could ever want, the prostate lives a very isolated life. You can’t see it, you can’t feel it, men don’t know what it does, and they sure as heck don’t want a stranger probing around to disturb it or try to feel it.  Men feel unmanly with the very thought of a rectal exam and would just as soon not have the prostate checked. Men are told to self examine their testicles in the shower, and women to do breast exam often, but no one suggests that the male contort himself to examine his prostate. Its very location bespeaks of nature giving it no respect: and why does it have to be located right there where other unpleasant things occur?
  • Then the blood test PSA comes along and further complicates the prostate’s social life. Before the PSA was a test the only way to check on the prostate was a rectal exam. Now with the advent of this simple blood test, men and doctors will often substitute the PSA for the rectal exam. It is an easy sell; not doing a rectal exam makes a doctor’s visit much more pleasant for both the doctor and the patient. Everybody ends up being happy except of course the dejected and unchecked prostate. (One can have prostate cancer with a normal PSA.)
  • Even when the prostate tries to exert itself with prostate cancer it get little attention both because of the prevailing belief that prostate cancer doesn’t kill people and that it often occurs only in older men. Articles in newspapers and on the internet daily state that most men die with prostate cancer and not of it, despite over 200,000 cases diagnosed and 25,000 deaths a year. Society perceives breast cancer much differently, and more seriously, than prostate cancer.  This is reflected nationally by the emotional and financial support that advocates of breast cancer have on loved ones and resultant proceeds from breast cancer fund-raisers.
  • Many patients, but particularly men, will only go to the doctor if they perceive a problem with an organ or if a symptom presents itself. Unlike chest pain indicating a problem with the heart or blood in the urine a problem with the kidneys, early prostate cancer has no symptoms until it is too late to do something. Prostate cancers often originate away from the tube men urinate through; and as a result there will be no urinary symptoms until the prostate cancer has become fairly extensive. Men can have prostate cancer for years without any symptoms. Despite this men will almost always assume there can’t be a problem with their prostate because, “I pee fine.” Once again for the wrong reasons the prostate is left out and not invited to the party-no respect.
  • The final insult to the prostate is what happens to the male if you mess with it. Any treatment of the prostate for prostate cancer is associated, in varying degrees, how a male voids and his ability to get erections. If the hurdles in checking the cancer weren’t enough of a deterrent to early detection of prostate cancer, the idea of what can happen to the male after treatment further complicates the prostates life. It is almost as if it is mad about being ignored throughout its life having angered it and now that something has to be done to treat the cancer; the prostate exacts its revenge in the form leaking urine and sexual dysfunction. These two maladies strike right at the heart of the male ego.

 

“Hell hath no fury like a prostate scorned.”

A conversation between a urologist and a friend at a party make the above points nicely:

 A urologist was asked by a friend, who was 49, at a party when he should have his prostate checked. The urologist said the blood work and exam could be done in less than five minutes, and he could come by anytime at the end of his work-day through the urologist’s office back door, and have the exam performed for free. The friend said that he was having no symptoms. The urologist said that having no symptoms is irrelevant. The friend then said he had had a colonoscopy and asked if that checked the prostate. The urologist said no, that was a different organ. The friend then said, like most people, “Isn’t prostate cancer a disease of old men?” The urologist said, “No,” and mentioned that Frank Zappa died in his 50s, three years after the diagnosis of prostate cancer, adding, “It can be a painful death.”,  making the point that it would be prudent for him,  at age 49, to be checked. The friend then said, “But Frank Zappa had a bad lifestyle.” The urologist replied that lifestyle was irrelevant, as well, as a risk factor for prostate cancer. In the matter of this two-minute conversation, this college-educated friend had verbalized almost all the half-truths regarding prostate cancer. He confirmed yet again why prostate cancer is often times diagnosed late, and revealed again why the prostate is the Rodney Dangerfield of organs, “It just don’t get no respect.”

When men acknowledge the respect which prostate cancer deserves only then will there be a heightened awareness, early detection and treatment in a more curable phase of prostate cancer.

“With my wife I don’t get no respect. I made a toast on her birthday to ‘the best woman a man ever had.’ The waiter joined me.”-R.D.

Dr. John McHugh is the author of “The Decision: Your prostate biopsy shows cancer. Now what? Medical insight, personal experience and humor by a urologist who has been where you are now.  Theprostatedecision.com and Theprostatedecision.wordpress.com

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From “The Decision”

On one particular occasion (however it has happened countless times) I had just told a patient that his biopsy showed cancer. I began to lay out an overview of the options and happened to start with surgery. Before I could continue, the patient told me, “My brother has a friend who has prostate cancer, and he did radiation because a doctor told him that if he had surgery he’d be impotent and that surgery lets air get to the prostate and will make it spread. My brother and his friend told me to steer clear of surgery.” Now, normally I will take a deep breath and slowly explain the pros and cons of both radiation and surgery and the concept of apples to apples, but sometimes I have a little fun showcasing the folly of how some patients will place so much credence on something someone has told them. On this occasion I said, “Mr. Jones, thank you for sharing that with me. What type of work does your brother do?” “He sells insurance.” “Thank you. And what type of work does your brother’s friend do?” “I think he builds houses.” I then said,” Okay. Based on what you have told me, this is what I’d recommend for your cancer. My advice to you would be for you to do what your brother said his friend was told by his doctor about your brother’s friend’s cancer. Do you have any other questions for me?”

There was a story that was in the news several years ago regarding claims made by several people that the Arkansas  State Patrol would secretly bring women to Bill Clinton when he was governor there. One lady in particular said that Clinton undressed in front of her in a hotel room and that she saw something about him that could prove that he did what she claimed he did. The thing she noticed was never publicized or reported but it was something that she said was “proof positive” that she had seen Clinton without clothes one.

I know what it was. It is a urologic condition that is only noticable if the male is erect. (Follow me here….everything always goes back to urology, prostate cancer, dogs or fish.) I also am a student of politics but try to leave that out on this site…most of the time….the doctors in white coats at the White House supporting Obama’s Health Plan was too much to not to comment on or make fun of….but  I digress.

So here’s the quiz question for today: What urologic condition can only be noted by an observer of a male in the erect state ? This condition cannot be detected by an observer in the flaccid state. 

I know this is very interesting to all of you and that the anticipation of the answer  is killing you. Don’t get bent out of shape….here’s the answer.

Peyronie’s disease.   In this disease there is a fibrous “plague” on the expandable tissues of the penis that in the erect state prevents that portion of the tissue to expand. This in turn curves the penis in the direction of the plague and only detectable when the penis is erect. I would bet that this is the “characteristic finding peculiar to Clinton” to which the lady claimed she saw.

What’s neat about this claim and why it could be used in a novel or detective story is that not only would the person have to be naked, which you can’t prove happened, but there would have been a condition that the accuser, would only know or could testify to, if the defendant was both naked and erect. Brilliant. As you know nothing came of the law suit however we do not know if there was a settlement…. I bet there was because I could have been an expert witness to confirm the lady’s claims from purely a urologic perspective.

So what does this have to do with the link above to the year journey of  the gentleman’s prostate cancer.

Just like the Lockerbie bomber and the lady’s claims about Clinton, as you learn more about prostate cancer and the nuances you can piece together the unsaid or unwritten part of a person’s journey with prostate cancer. Apples to apples, prostates to prostates is how I describe this in my book.

Here are some salient points to get you started. You then read this man’s story…(I haven’t but I don’t need to) and see if you can pick out favorable stuff or unfavorable stuff. Knowledge is power, past is prologue. This actually brings up an interesting point. Do you want to know your prognosis if you have recently been diagnosed with prostate cancer? Do you want to know if your parameters or favorable or not? Well…you do need to know the difference between favorable and unfavorable factors because that might help you decide to value cure over ease of treatment. Knowledge of good signs or bad signs may or may not determine how aggressively you view your cancer and subsequent treatment decisions. Just because uncle Bob did good with his cancer doesn’t mean you will do with yours. It is prostate cancer, but ” ain’t all prostate cancers the same” my frin. 

See if you know which of the following are good or bad, favorable or unfavorable and how each would affect a patients course or ones decision:

  •  a treatment that results in a low PSA that stays there and there is no other treatment given….ever.
  •  additional treatment is necessary…whatever it is
  • the PSA changes upward after the initial treatment
  • there’s evidence prostate cancer in the bone or lymph nodes
  • the path report of a removed prostate reveals perineural invasion
  • the path report reveals seminal vesicle involvement
  • a Gleason’s 6 versus a Gleason’s 8
  • the path report of the biopsy has only one of 12 positive for prostate cancer
  • the biopsy path report has 10 of 12 positive cores
  • you are young when diagnosed
  • you are old when you are diagnosed
  • the radiation therapist wants you to be on hormone therapy before he begins radiation treatment
  • hormone therapy corrects the elevated PSA and then the PSA comes back up on hormonal therapy
  • you are on casodex, your PSA rises, you stop the casodex, and your PSA goes back down
  • you have had radiation with pellets (brachytherapy) and at about 18 months the PSA begins to rise…reason to worry?
  • PSA bounce after radiotherapy
  • the path report of the prostate removed has extra-prostatic extension
  • the path report of the prostate removed shows capsular penetration
  • the prostatic acid phosphatase is elevated (bet you don’t know this one)
  • Gleason’s 6, small biopsy volume, path without seminal invasion,no capsular invasion, in the center of the gland away from the apex, urethra margin and away from seminal vesicles, small volume on final prostate path report

This is just the start of it…. and the reason the “Decision” is so hard…the above doesn’t even consider all the potential affronts to the male ego as it relates to continence and potency. That is a whole “nother” chestnut.

So when it comes to prostate cancer and you read about it or hear about it from others….read between the lines and consider everything.

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Pepe the prostate

 

Interview with Mr. PSA- Part Two 

Dr. McHugh: “Welcome back. I am with Mr. PSA and his pseudonym Pepe the prostate. How are you tonight and again thanks for being here with us to shed some light on the dilemma that is PSA and prostate cancer.” 

Mr. PSA: “Thank you, again it is good to be here. There has been a lot of misguided press since I was here just 24 hours ago. I think my thoughts and insight into this issue will be helpful.” 

Dr. McHugh: “This logo of yours. What is that about?  It looks like a child did it. Some sort of Zeus character? Are those lightning bolts coming from your head? I’m sorry. Is this really sending the message you want to get out there?” 

Mr. PSA:  “Okay, the lightning bolts are the seminal vesicles. They represent my ears. The little things that look like legs are the vas deferens, and the shoes are well… they are testicles. Clever huh? I am very pleased with my logo. You have to be somewhat into prostate cancer and the prostate to get it. The fact that you did not get it speaks volumes about you and your inadequacy to do this interview. Just kidding, kinda. Now what else do you have for me?” 

Dr. McHugh: “I am a urologist my friend. I get it. I am talking about the public. The guy that has been recently diagnosed with prostate cancer. Are you over his head with your little interpretation of a prostate? And anyway, what is the prostate cancer connection?” 

Mr. PSA: “You remember Pepe le Pew don’t you. The romantic skunk with a French voice and high libido? The prostate  has testosterone in it, it converts testosterone. That’s how proscar works. Anyway it all ties in, it puts a face on the PSA so that folks will be more sensitive about putting me down.” 

Dr. McHugh: “What are your ,thoughts on the AUA response to the ACS remarks about you? You align yourself politically more with the AUA than with the ACS don’t you? Is that a fair statement?” 

Mr. PSA: “Of course I lean more toward the AUA, this is an organization that represents practicing urologists, the guys out in the field actually doing the day to day work in prostate cancer. What I found interesting about their response was that they said in one paragraph that they appreciated and supported (not agreed) the ACS statement, then in the next made the point that proceeding to a biopsy was a multifactorial process that included the patient, me, my density as it applies to the size of the prostate, my free value,the age of the patient, the health of the patient, the change over time of me and on and on. What came to mind is your book, “The Decision,” you address the relevant factors that go into making the “decision.” Its a complicated situation. 

Dr. McHugh: “Thanks for plug. I personally have been a big fan of yours and I feel that everybody needs to remember, hey, “don’t just throw the baby out with the bath water.” I think you are still relevant. I really do.”  You mentioned that one of the factors mentioned by the AUA was a free PSA. Have you gone generic? What is the free about?” 

To be continued….

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Mr. PSA-"I have feelings too!"

Dr. John C. McHugh of Prostatediaries interviews PSA

 Dr. McHugh: “So first of all thanks so much for coming on the program.”

PSA: “My pleasure. There’s been a lot of bad press out there and I appreciate the opportunity to respond.”

Dr. McHugh: “You look young. How old are you, if I might ask?”

PSA: I am about 24 years old. I really did not get popular until the late eighties.”

Dr. McHugh: “Well, let’s get to it. A lot of people are saying that you have somewhat saturated the market, that your value in the prostate community is waning. Many people feel that you are responsible for perpetrating upon the male population a bunch unnecessary misery. I guess you have become fairly thick skinned over the years.”

PSA: “I really don’t know where to start. You know it’s not like I am forcing myself on people. There are about 30,000 deaths from prostate cancer a year in the United States and it is the most common tumor in men. I help find it and hopefully in many cases detect it early and save lives. It’s all about early detection in cancer you know.”

Dr. McHugh: “Do you think all this recent press about you and over diagnosing cancers that don’t need to found or treated in the first place is a jealousy thing.”

PSA: “You make a good point. The breast and the colon, and for that matter the lung, would kill for a marker that could be done with a blood test and facilitate the diagnosis of cancer in them earlier.”

Dr. McHugh: “For our “new listeners, tell us a little about yourself.”

PSA: “I am glad you asked. I am a subsidiary of the prostate gland. Man, God had a sense of humor when he created that thing. It gets bigger as men age and serves no purpose but to cause problems by either turning into cancer or enlarging to the point that men can’t pee. The very thing or other organ that men would hope to get bigger actually gets smaller and quits working. Go figure. Anyway, be that as it may, the cells in the prostate normally produce a product like me, but prostate cancer cells produce more of it than they do. So if I am elevated in the blood there is the possibility that there are cancer cells producing it, i.e. the man has prostate cancer. I’m probably the most specific marker for cancer there is.”

Dr. McHugh: “But isn’t the problem that you are elevated sometimes when there is not a problem. “You “cry wolf to often” so to speak. Do you agree with that statement?”

PSA: “Cry wolf, wow that is choice.”

Dr. McHugh: “False positive readings, you are high and there’s no cancer. Lots of unnecessary pain, money, tests and emotional upheaval because of you man. What do you say to that?”

PSA: “What do you say about Jesus leaving the 99 sheep to find the one?”

Dr. McHugh: “Insurance companies would beg to differ. They would ask,” Who is going to pay for the 99 if they are lost? They’d put their time and effort in the 99. It is not cost effective to lose 99 sheep to save one. You’d agree with that wouldn’t you?”

PSA: “Hey, don’t shoot me. I am just the messenger!”

Dr. McHugh: “So what’s in it for you? Are you making money on this? Is the prostate behind this?”

PSA: “The prostate? Are you serious? It’s the male patient. He’s the conductor driving this train my friend. Then there is the doctor who will be sued if he misses a prostate cancer in a male patient because he did not use me. You see that don’t you. Visualize your brother going to the doctor for bone pain and prostate cancer is detected all over his body and the doctor had not used me, Mr. PSA, to help make sure that he did not have prostate cancer. I was not used because the doctor did not want to put your brother through the anguish of obtaining me and possibly subjecting him to a prostate biopsy. He was doing your brother a favor. The doctor spent twenty minutes on the informed consent about me and how it might lead to unnecessary tests and pain and your brother who doesn’t like the thought of rectal exams anyway declined the evaluation thinking he was smart, medically progressive. He’d read the news reports everyday about how bad I am. It was easy, “No, I don’t want a rectal exam, the blood test or any of the stuff that goes with it. Stuff that happens in prison all the while running rampant through his mind as the doctor is talking and giving him his options. He remembers a friend telling him that his father was 90 when he died of prostate cancer and the doctors,” didn’t even treat it.”

Dr. McHugh: Well PSA, you sound somewhat defensive to me. Biblical allusions, sarcasm and then, trying to personalize your point by referencing a family of mine to make your point? What’s up with that, are you angry?”

PSA: “In a way I am. If I asked you, if you were the lost sheep, would you want to use me to find you; even if it meant searching through the other 99 to find you? How do you feel about that? How would you feel if it were you that we were trying to save earlier? Would you be concerned about the time, effort and cost it took to save you? That my friend, is the question and the dilemma we find ourselves in. Tell me about how you would feel if it were you! Think of the old time worn and tested saying, “Follow the money, there is the answer.”

Dr. McHugh: “That is all we have time for tonight. Please join us next time for Part Two of my interview of PSA. Good night all.”

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http://www.medwire-news.md/46/85879/Oncology/PSA_screening_may_be_unnecessary_in_certain_men_over_75_years.html

My thoughts-

The interesting thing about this article has to do with something that happened to me about a month ago. I have been treating an elderly male for symptoms of an enlarged prostate. He was on two medicines for that and was getting along quite well. I had examined his prostate about two years ago, he was 82 at the time, and it was mildly asymmetrical but for his age unremarkable. He, a friend of his, and I all agreed that because of his age and other medical problems that we would stop getting PSA’s and doing rectal exams. Recently he was in the hospital for a heart condition and on chest xray was noted to have an abnormality of his ribs. This prompted
a bone scan revealing wide spread metastatic bone disease. A PSA was obtained by the cardiologist and the value was over 1300. His daughter calls me to tell me that her father that has been under the care of a “urologist” for two years has widespread metastatic prostate cancer. So. These studies and others that you may read that may regard to other various medical topics have to be taken with a grain of salt. I personally will continue do rectals and occasional PSA’s on my older healthy patients. I can quote all the studies I want to this family, but they feel that I allowed prostate cancer to progress in a loved one under my care. This type of stuff happens all the time in medicine and again showing why the practice of medicine, “is an art and not a  science.”

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