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Posts Tagged ‘frank zappa’

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My dear buddy Jo An Baldwin Peters made a comment on one of the posts yesterday and mentioned that her husband needed a MRI. They live in Canada and she related that the MRI had been scheduled some time in 2013. She mentioned, “Wait until the U.S. gets health care.”

I mention this to say that it is difficult to get a PSA approved in the U.K. because of the criteria that must be met by the family M.D. to justify the test. Keith Cass makes this point on his website www.theredsock.co.uk

So enter a healthy asymptomatic male in his early 40’s to my office last week who because his father had prostate cancer, his family doctor ordered a PSA. He is in turn sent to me and has a normal rectal exam. We elect to do the prostate biopsy and it shows 5 of 12 cores positive for Gleason’s 7 prostate cancer.

Is there anyone in the audience who would argue that he should not have had a PSA drawn? Or that the above scenario will have no impact on his longevity had it not been discovered? Or that, “Well yes it found something this time or this patient, but you can’t do that on everybody. It would be too expensive to test so many people only to find this guy every so often. (You know that is the argument.) Wonder what this particular patient would say to that argument? What do you want for your father, husband or brother.

What say you?

From a CME test I took earlier today…

Screening for Prostate Cancer: A Review of the Evidence for the U.S. Preventive Services Task Force.

Chou R, Croswell JM, et al: Ann Intern Med; 2011;155 (December 6): 762-771

Objective: To review the results of recent PSA studies and to summarize this evidence.

Design/Methods: A systematic review (SR) and meta-analysis (MA) of the data were performed for randomized, controlled trials (RCTs) and cohort studies looking at PSA screening and treatments for prostate cancer (PC). The study focused on 4 questions: does PSA screening decrease mortality, what are the harms of screening, what are the benefits of treating early or screened PC, and what are the harms of early treatment?

Results: Conflicting results on PC mortality were seen from 3 specific RCTs, 2 showing benefit and 1 no benefit. Serious infection or urinary retention from biopsy occurred in 1 in 200 men. A 6% absolute survival benefit from radical prostatectomy (RP) versus watchful waiting (WW) was reported from a high-quality RCT, and cohort studies reported consistent benefit to RP and radiation therapy (RT) over WW. Harms from these treatments were erectile dysfunction (ED) in 1 of 3 men after RP, in 1 of 7 men after RT, and incontinence in 1 of 5 men after RP.

Conclusions: Current population-based PSA screening detects more early prostate cancer but results in a small, if any, increase in survival. There are measurable risks of biopsy and significant harms of early treatment.

Reviewer’s Comments: The U.S. Preventive Services Task Force PSA recommendations have sparked a controversy over PSA testing that has forced many stakeholders, including physicians, patients, and ultimately policy makers, to form an opinion on the future of men’s health care. This review presents a well-developed summary of current evidence on PSA screening and standard treatments for PC. What is not immediately clear is how this synthesis should lead to a recommendation against all future PSA screening, as advocated by the task force. Arguments against the task force’s extreme position abound. Final decisions regarding mortality from screening tests should not be made based on early reporting, yet the RCTs included here are only at 9 to 10 year follow-up for a disease with up to a 25-year progression. It may also be inappropriate to combine the data from these trials, as they are extremely heterogeneous in the screened and “unscreened” populations. The number needed to treat cited (48) for survival is likely too high. Estimates from the European Randomized Study of Screening for Prostate Cancer are 12 to 20, and the U.S. Prostate, Lung, Colorectal, and Ovarian subgroup analysis suggests 5. Finally, even without an overall survival benefit, many would argue that the reduction in metastatic and local disease morbidity has provided a significant benefit to the way men currently experience prostate cancer. We should certainly accept the current limitations of PSA, as laid out extremely well by the task force. However, rather than abandon it, we should pursue improvements in its current application.(Reviewer–Steven E. Canfield, MD).

 
© 2012, Oakstone Publishing, LLC

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You can't turn back the clock. But you can wind it up again. - Bonnie Prudden

ProstateMd in the Itunes app store

I know what you are thinking….I shouldn’t have used Penelope as the background of the app…well…that’s what makes me different….irreverent informative prostate cancer stuff with an edge and a bit of humor…..

Well…a few months ago a friend of mine, well kinda sorta of a friend….I hate people and most insects….recommended that I have an app for prostate decision making.

I thought what good would that do? Here’s the deal. I eat lunch behind my ambulatory surgery center every day I can and listen to the radio and read stuff on my iphone. In other words there are those of us that are in certain areas without a computer and but want to do computer stuff.

Look around you…folks all around are looking at their phones in lines at the grocery store, on benches, in the waiting room, in the exam room and most commonly…while you are talking to them.

So…a prostate cancer decision-making app for those folks.

No market for a prostate cancer app you protest especially since all the talk that the PSA is a bad ole nasty test and the urologists recommending them are money hungry charlatans!

Well…16% of american men have it, I think that is one in six and that represents 250,000 new cases a year.  That is, I’d say, a reasonable market for the app.

I went on the App store and guess what? Not much there on the subject of prostate cancer.

So…I am putting a “boat load of info” on this app. The app service I have allows me to update seamlessly and in real-time. So today I uploaded all the treatment methods out there and my take on it. Good stuff…and the app allows the user to send as email, or post to Facebook or twitter. So if you purchase the app and want to help a friend who has been recently diagnosed….well…..

Viola!

Finally, I plan to set up a reward program for the “Best comment or question of the week.” If someone submits an issue and I use it as a post or for something on the app…I’ll autograph a book and send it out free of charge once a week. Not to shabby…huh?

I really think the best function of this app is access to info while one is on the run and would not otherwise get all this info in one place. Just like me behind my surgery center at lunch.

I hope it will help someone who otherwise would not have taken the time to learn about this tricky disease.

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"Some of us think holding on makes us strong; but sometimes it is letting go."- Hermen Hesse

 The article below is one of the few times I have actually seen written the concept of a low PSA and prostate cancer. Why is it important?

Because often times men will have a physical exam by their family doctor and everything is checked but the prostate by rectal exam. (Remember the article that stated that 70% of men have never had a rectal exam.)

How does this happen and why? Well men don’t like a rectal exam. The family doctor gets a PSA with his normal blood work along with the chemistries, CBC, etc and it comes back normal. The patient is told that the PSA is normal and it ends there. Everybody is happy, the doctor did not have to do the rectal exam (doctors don’t especially like doing the exam either…that’s why there is a specialty called Urology) the patient did not have to have the exam, and the patient got good news, the doctor “checked for prostate cancer” and nothing is done for the next year.

What is the chance that the above situation would miss a cancer? Well…not very often. But…it is a tragic situation when a relatively young man religiously goes for his annual exam since age 40, never has the rectal exam but does get the yearly “normal” PSA and then at age 48 the PSA does go up or he has voiding symptoms and a rectal is done, is abnormal, prompts a prostate biopsy and viola…he has inoperable prostate cancer just like Frank Zappa and Bill Bixby had.

Have I seen this happen? Yes. Often?…No. But I have been in the room with the family of the unfortunate man and the wife asks, ” How can it be that he has gone for all the check-ups he was told to go to over all these years and you are telling me he has inoperable prostate cancer?”

Then the explanation that prostate cancer can be tricky and that some very aggressive forms don’t produce PSA the way the normal glands or less aggressive glands do. My explanation offers little condolence.

One other thing…really bad cancers lose all of the characteristics of normal cells. They can become so bizzare the pathologist has trouble determining what cell type or organ it came from. Often times the only way they know it’s a prostate cancer is that they know that the tissue came from the prostate. When a prostate cancer is bad…it can be very bad, i.e. high Gleason’s Score.

So what to do…do the rectal with the PSA and everyone should be diligent about it. How? Through knowledge of the disease and its variations.

Ps…Just did surgery on a man named Dillinger. How about that?

Who was “The lady in Red?”

 

Do men with higher PSA levels have a better prognosis than men with lower PSA levels?

August 29th, 2011 Posted in prostate cancer diagnosis The PSA level helps determine how likely it is that the cancer has spread (metastasized). It also helps determine how likely the cancer will be cured with treatment such as radiation or surgery. Generally, the higher your PSA level and the faster the rate at which it increases, the more prostate cancer cells you have in your body.

In some cases, the PSA level may not be elevated, despite the presence of prostate cancer. In such cases, the cancer cells often have more genetic mutations than other prostate cancer cells do, and they don’t have the ability to make PSA. This type of prostate cancer is usually more aggressive and doesn’t respond well to treatment. Some scientists believe that the genetic mutations in these cancer cells may allow such cancers to grow and spread more quickly.

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whether you think you can or think you can't...you're right

First off all…look at the sentence I highlighted in bold. Are you kidding me? Concerns about a CT scan and radiation all the while finding no complaints regarding treating the prostate cancer with radiation regardless if it’s seeds, Proton, or external beam.

The use of “misuse” is an attention getter is it not.

We have known for years that the likelihood of a positive bone scan for bone metastasis and a positive CT scan showing pelvic lymph note involvement is low in the patient with low Gleason’s and low volume disease on his prostate biopsy report.

In today’s world I as a urologist can tell the patient that biopsy shows cancer and then say, “The chances of finding anything on a CT scan or bone scan is low. It is however a part of the staging work-up for the newly diagnosed prostate cancer patient. Would you rather not do these studies? The patient decides based on the information that I have given him. These test are most commonly negative…but not always. What is the consequence of not doing the tests in the face of unknown metastatic disease? Well you get your prostate out, or get radiation, or HIFU, or cryosurgery for local disease when in reality it is not. Are you Okay with that?

You see what all the studies and reports fail to “get” is that statistics are different from actually sitting down with the patient and family and making decisions.

I guess with a National Healthcare Plan…the doctor will just say, ” Your prostate biopsy shows cancer and there is no need to do a bone scan or CT scan based on statistics of similar patients with a biopsy like yours.” Done.

Which is right or which is wrong? Well…everytime I make the diagnosis of prostate cancer someone somewhere sends me a form to fill out about the stage of Prostate Cancer my patient has. Well…if I don’t do a bone scan and a CT…I am assuming. Maybe the forms…i.e. the National Cancer Registry, or your local hospital’s Tumor Board has a little box to check stating the stage is I but that because of parameters of the biopsy a staging work-up was not done. As of yet and as of today…that box does not exist, but I am continually having to stage my patient’s cancer on some form.

So what to do?

Doctors misuse scans? Is it really that simple? Dear Dr. McHugh quit doing bone scans and CT’s to stage your patients. Also please fill out the attached form informing us of your patient’s prostate cancer stage or risk losing your hospital privileges until your medical records are up to date. What’s a doc to do?

Regarding the title of this post-My patients, after I have explained the likelihood of the results of the scans, most commonly opt to have the studies done. It is more information about their cancer and allows them to make treatment decisions. Right or wrong? What would you do given the choice?

What did I do? I did not have a bone scan or CT.

Doctors misuse scans in prostate cancer: study

Fri, Aug 26 2011

By Genevra Pittman

NEW YORK (Reuters Health) – Too many men with low- or medium-risk prostate cancer get CTs and bone scans that aren’t recommended for them, suggests a new study.

The scans are intended to tell doctors if cancer has spread beyond the prostate in men with high-risk cancer.

Doing them in other cases is a concern because CTs expose patients to small amounts of radiation — which itself is linked to future cancer risks — and the scans cost the healthcare system extra money, but have little potential benefit.

The research also suggests that not enough men with high-risk cancer get the scans, which means some of them may get treatment for local (confined to the prostate) cancer that’s unlikely to help if the cancer has spread.

“In high-risk patients, those are the ones that have a high risk of positive lymph nodes or (cancer that has) spread to the bone,” said Dr. David Samadi, a prostate cancer surgeon at the Mount Sinai Medical Center in New York who was not involved in the new study.

“Otherwise for low-risk disease, the likelihood of finding a positive bone scan or CT scan is low,” he told Reuters Health.

Guidelines from the American Urological Association say that doctors should use other measures such as prostate-specific antigen (PSA) testing to determine a man’s risk of advanced cancer and then only scan those with high-risk disease to determine the best treatment.

Researchers led by Dr. Jim Hu of Brigham and Women’s Hospital in Boston wanted to see how frequently those recommendations were being followed.

They consulted a database of U.S. men covered by Medicare who were diagnosed with prostate cancer in 2004 and 2005 — a total of 30,000 cases.

Both bone scans and CTs were more common in men who were diagnosed with high-risk cancer.

Sixty percent of those men had one of the scans. Still, one-third of men with low-risk cancer and almost half of those with medium-risk cancer had a scan in between diagnosis and treatment.

Hu and colleagues calculated that the cost of unnecessary scans in men with low- and medium-risk cancer billed to Medicare during those two years was about $3.6 million for their study group. (The government-run insurance program paid an average of $226 for each bone scan and $407 for a CT).

Extra scanning not recommended by guidelines “significantly increases Medicare expenditure without improving quality of care rendered for men with newly diagnosed prostate cancer,” the authors wrote in the journal Cancer.

And each extra CT scan exposes men to a small amount of radiation, while also providing an opportunity for doctors to catch something “incidental” that may not pose a threat but still leads to more testing or procedures, Samadi said.

Another recent study found that coaching and feedback from peers about the proper use of the tests helped prostate surgeons reduce the number of unnecessary scans they ordered. Samadi thinks many doctors are just trying to be on the safe side by ordering more tests.

“A lot of it has to do with the fact that most urologists when they think of prostate cancer it’s almost like a knee-jerk reaction — automatically they think bone scan and CT scan,” Samadi said.

The researchers noted that finding four in 10 men with high-risk cancer aren’t getting a scan is also “worrisome.”

If doctors don’t recognize that cancer has spread in some of those men, they said, they won’t benefit from treatment directed just at the prostate.

SOURCE: bit.ly/pYwBrh Cancer, online August 5, 2011.

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god gave burdens...also shoulders

New Robotic Surgery Technique Maintains Sexual
Function After Prostate Cancer Surgery

The SMART Technique (Samadi Modified Advanced Robotic Technique) Enhances
Surgical Precision and Maintains Sexual Wellbeing After Prostate Cancer
Treatment

Dr. David Samadi, Vice Chairman, Department of Urology, and Chief of Robotics
and Minimally Invasive Surgery at The Mount Sinai Medical Center knows the wide
range of emotions and fears that men with prostate
cancer
face. As a robotic
prostatectomy
and prostate
cancer treatment
 expert, Dr. Samadi cares for the total patient, helping
them deal with all aspects of treatment, recovery and cure. Robotic
prostatectomy procedures, performed to remove the prostate gland and surrounding
cancer, can provide excellent cancer cure results, though many men fear the
potential side effects of the surgery. Top on their list of concerns: will they
be able to have and enjoy sex
after prostate cancer treatment
?

Dr. Samadi understands this concern. “For most men, sexual function is
equally as important as eliminating prostate cancer. Many of their fears about
sex after surgery are carry-overs from what they know of older open and
laparoscopic prostatectomy techniques. Thanks to robotic
surgery
, these fears can be greatly reduced.” Historically, the prostate
gland was removed through invasive surgery during which surgeons had a difficult
time sparing the tiny nerve bundles responsible for erectile and sexual
function. Often, a man’s ability to have sex after surgery was negatively
impacted. With the advent of robotic surgery techniques, experienced surgeons
like Dr. Samadi have an enhanced view of the prostate gland, allowing increased
precision and dexterity. As a result, the risk of damage to the nerves vital to
sexual function is significantly diminished.

When treating his prostate cancer patients, Dr. Samadi employs a
start-to-finish approach, including an individualized evaluation of sexual
function prior to surgery and on-going, post-surgical assessments of options to
aid the return of sexual function. “I consider robotic surgery successful when
the cancer is cured and the patient has full continence and potency. All three
criteria must be met for me to consider the surgery a success.” Dr. Samadi dubs
this whole-patient approach, “Treatment Trifecta.”

Dr. Samadi customizes robotic surgery with his own SMART
(Samadi Modified Advanced Robotic Technique) method
. Using the da Vinci
System, the commonly recommended treatment for localized prostate cancer, Dr.
Samadi is able to perform highly precise movements at the surgical site:
cancerous tissue is cleanly removed and critical nerves are spared. By not
opening the surrounding fascia around the prostate and not suturing the dorsal
vein complex, Dr. Samadi has improved the quality of men’s post operative sex
life. Ultimately, this leads to faster recovery and an improved outlook for
regaining sexual function and urinary continence.

“Men want to know they can return to a normal life when this is all over.
They want the cancer gone and they want to move on and enjoy sex the way they
always have,” says Dr. Samadi. While the resumption of sexual potency can take
up to 12 months or more, Dr. Samadi assures patients that this is within the
normal course of recovery. His comprehensive approach to prostate cancer
treatment and sexual wellbeing continues beyond surgery. “It’s not uncommon for
men to experience some ED immediately following prostatectomy procedures, but
this is not an indication of their long-term sexual potency. I continue to work
with patients to achieve the complete results they desire.”

More can be seen from prostate cancer expert, Dr. Samadi, who is also part of
the Fox News Team.

Prostate
Cancer Treatment Options Compared: Robotic Surgery vs. Watchful Waiting

Robotic
Surgery on Good Day New York

Related Links:

http://www.smart-surgery.com/

http://www.roboticoncology-it.com/

http://www.roboticoncology-il.com/

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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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