Posts Tagged ‘psa’



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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Ben Stiller’s misguided prostate cancer recommendations aren’t based on evidence-healthnewsreview.org

No it is based on examining the risks of the disease and the risks of the treatment and making a decision he felt was best for him. Regardless of your position on Mr. Psa 30,000 men a year die of prostate cancer. How is that?

Kevin Lomangino is the managing editor of HealthNewsReview.org. He tweets as @Klomangino.

Comedic actor Ben Stiller clearly had the best of intentions when he decided to write about his experience with prostate cancer and urge men to get a prostate specific antigen (PSA) test starting at the age of 40 – advice which contradicts the guidelines of all major professional organizations.

I admire Stiller’s intention to help out help out his fellow man, and I am glad to hear that he’s apparently doing well and satisfied with his treatment choices. I also applaud Stiller for acknowledging the controversy surrounding PSA testing with the following:

The criticism of the test is that depending on how they interpret the data, doctors can send patients for further tests like the MRI and the more invasive biopsy, when not needed. Physicians can find low-risk cancers that are not life threatening, especially to older patients. In some cases, men with this type of cancer get “over-treatment” like radiation or surgery, resulting in side effects such as impotence or incontinence.

That’s important context that’s often missing from similar celebrity health stories — and he also tells men to have a discussion with their doctors about the test. That’s certainly the best way for men to sort through their options and make an informed choice.

My problem with Stiller’s piece is that it makes a number of false or misleading assertions and fails to accurately reflect the evidence on prostate cancer screening. And because Stiller is smart, persuasive, and famous, his skewed piece may do a great deal of harm to men who may be led astray by his faulty reasoning.

NO PROOF that a PSA test saved Ben Stiller’s life

The most glaring problem with Stiller’s argument is that it’s built on a false assumption. He says, “Taking the PSA test saved my life. Literally. That’s why I am writing this now.”

He can’t say that with any certainty.

The facts are these: Prostate cancers vary in their aggressiveness, and some very aggressive cancers will prove fatal despite early detection and treatment like Stiller received, whereas the majority grow slowly and might never pose a problem to the patient. Stiller says his cancer had a Gleason Score of 7, but doesn’t offer full details about his case that would allow experts to assess the likelihood that he’d benefit from prostate removal. Even with those details, it would be impossible to know for certain whether his cancer would have spread or not.

For that reason, no one-including a celebrity with greater-than-normal access to top-notch healthcare–can say whether the test saved his life, or merely detected a cancer that could have been monitored and might never have bothered him.

Here’s how oncologist Vinay Prasad, MD, MPH, explained the flaws in Stiller’s logic to me:

Before embarking on any screening test, a physician MUST council a patient about harms of screening, including false positives and overdiagnosis–where a real cancer is found and treated, but it would not have caused the person problems. Ben Stiller’s strong faith that the test “saved his life” is incompatible with a true understanding of overdiagnosis. If he really understood overdiagnosis, he would understand that he could not say this definitively. Gil Welch has shown that often most people with breast cancer diagnosed by screening cannot claim to have their life saved. The same principles that apply in this study also apply to prostate cancer, and no person whose cancer was found by PSA screening can say definitively, “The test saved my life.”

HealthNewsReview.org contributor Douglas Campos-Outcalt, MD, agreed that the evidence cuts against Stiller.

When someone says “Taking the PSA test saved my life,” they have over a 95% chance of being wrong. There is a spectrum of aggressiveness in prostate cancers. The vast majority detected by screening are not aggressive and screening does more harm than good in these men. The most aggressive forms are not helped (usually) by screening because they are too aggressive and are not asymptomatic long enough to be detected by screening. The moderately aggressive tumors are the only ones that can benefit from screening and the unusual man who has one of these detected by screening may have their life “saved,” but this is offset by the number killed by the treatments and the large number who are left impotent and incontinent.

Here’s an evidence-based infographic from the Harding Center for Risk Literacy that explains the numbers – note that for every thousand men screened, up to 160 false positive tests will occur and up to 20 men will be treated unnecessarily (risking harm from unneeded surgery) with no clear mortality benefit.


Although Stiller dismisses those harms – incontinence, impotence, among others — as being “in the purview of the doctor treating the patient” (whatever that means), the fact is that the treatments themselves can be deadly or cause serious disabling side effects. Even the biopsy resulting from a false-positive PSA can lead to serious infections requiring hospitalization and – rarely – death.

In fact, the treatments can be so grueling that it’s possible they may increase other causes of death – canceling out any reduction in prostate cancer deaths. That’s why Prasad and others argue that overall mortality, and not prostate cancer mortality, should be the benchmark to assess benefits from cancer screening.

Celebrities have a responsibility to use their platform wisely

Another problem with saying the PSA saved his life: He might still die from prostate cancer, in spite of being tested. Sadly – and I very much hope this is not the case – it’s possible that Stiller’s cancer is one of the aggressive ones that will recur despite early detection and treatment – meaning that Stiller’s declaration of having his life “saved” will turn out to be premature. This is a reality that needs to be acknowledged. Everyone needs to choose their words carefully when addressing a topic as deadly serious as cancer.

That’s especially true for celebrities, who in our culture have an outsized platform to express their views. Timothy Caulfield, who studies celebrity health messaging at the University of Alberta, calls Stiller’s post “exactly the kind of celebrity advice that is not needed.”

The message that is conveyed by Stiller’s post is that PSA testing is a benign procedure (“it is a simple, painless blood test”) that only has upsides – that is, if you have the right doctor (how a patient is suppose to know this, isn’t clear). But his personal story is not evidence. This is a well-told anecdote, not good data that demonstrates that PSA testing is worthwhile. It is advice that can only confuse the public discourse surrounding PSA testing. More important, it runs counters to the emerging evidence-informed consensus that, for most, PSA screening is not helpful and may be harmful. But because the advice is coming from a celebrity, it will get pop culture traction and could encourage the utilization of a test that has questionable value.  And, alas, we also know that a powerful narrative, like the one in Stiller’s blog, can overwhelm even a mountain of good clinical data.  Bottom line: not helpful.”

How much traction is this getting? The Today Show, with its audience of millions, has already had Dr. Mehmet Oz on the show discussing the piece and its implications. It was great to see the sometimes evidence-challenged Dr. Oz pouring some cold water on Stiller’s claims and citing U.S. Preventive Services Task Force data on the very modest benefits — and considerable harms — of PSA screening.

Caulfield gives Stiller points for engaging the controversy around PSA testing and referring to the relevant policy statements. However, I’d note that Stiller’s thesis appears to reflect the views of his urologist, Dr. Edward Schaeffer, who’s helped promote fear-mongering messages about “skyrocketing” rates of prostate cancer due to reduced PSA testing. Those statements aren’t based on sound science as I pointed out in a post a few months ago.

Skewed statistics can certainly stir up fear that would lead to blog posts about the need for more PSA testing. But such posts telling personal stories are no substitute for a comprehensive assessment of the evidence. The choice that was right for Stiller is not right for everyone.

“Frankly, I am sick of celebrities telling anecdotes about cancer screening,” says Prasad.  “Screening is too important to too many people, and has too broad public health repercussions.”

Prasad adds: “When celebrities choose to volunteer some, but not all, of their health information they may affect health decisions for many Americans (as was seen with Angelina Jolie). As such, celebrities have a responsibility to do so wisely. I am afraid Ben Stiller’s post does not meet this mark.”

Note: Please see the comments section for additional commentary from Dr. Prasad that was edited from the post for length.

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Kevin Lomangino

October 5, 2016 at 11:36 amThe following comment is from Vinay Prasad, MD, MPH, whom I interviewed via email for the main post above. I edited these comments from the post to improve readability, but I think the point is worth sharing.

Ben Stiller says “I was lucky enough to have a doctor who gave me what they call a “baseline” PSA test when I was about 46.” He notes this runs counter to the USPSTF and even the ACS. Ben Stiller says everyone over 40 should get a PSA, but why does he discriminate against 39 year olds? If you accept Ben Stiller’s logic, that we should do anything to find cancer early (with near total disregard for net effects, harms or overdiagnosis), why is 40 Ben Stiller’s cutoff? He criticizes the American Cancer Society for 50, and yet equally arbitrarily chooses 40. If Ben Stiller thinks a 40 year old should be offered a PSA, why not a 39 year old? Why not every man? Since Ben Stiller does not employ careful scientific reasoning to reach his position, I would argue that Ben Stiller is logically inconsistent.

If he believes we should do everything possible to prevent advanced prostate cancer (and that seems his position), the test should be offered to any man of any age. Also, if Ben Stiller was to push his own thinking, he would argue that a prophylactic prostatectomy should be offered to any informed man. After all, PSA screening misses some prostate cancer– he conceeds that. Why should a healthy person not be allowed to remove their prostate beforehand? Since prostate cancer accounts for 2-3% of all deaths, the number needed to treat would be 33-50, and not that dissimilar from the most optimistic estimates of the PSA from the European randomized trial. Actually, Ben Stiller–since he thinks cutting out cancer early is the main priority and does not seriously weigh harms and overdiagnosis– should support the prophylactic removal of all un-essential organs, as any may become cancerous.

The purpose of this thought experiment is to illustrate the absurdity with Ben Stiller’s position: a slight more aggressive, slightly less evidence based recommendation the ACS. He is surely entitled to his opinion, but unfortunately his celebrity status will give that opinion disproportionate influence.

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those wounds healed only by time are the hardest to bear and relinquish John McHugh

I got a big kick out of this article about the Proton therapy machine and its application to prostate cancer.

First of all it is informative and several doctors of various persuasion are interviewed:

  • We learn that it is a very expensive machine to purchase.
  • It takes a very large building to house it.
  • There only ten centers in the US.
  • It cost a lot more to have done than “traditional” radiation.
  • The “experts” differ on if it is better than traditional.
  • The experts differ on if it really is associated with fewer “significant” side effects.
  • The proton  radiation hits the nerves of the prostate responsible for erections just like standard.
  • It hits the prostatic urethra (think irritative voiding symptoms) just like standard XRT.
  • It has fewer rectal “significant” complications than standard (they think.)
  • Institutions that have the machine run it all the time to capture the financial outlay for the machine.
  • Institutions that use the machine make more money using it than if they used the standard machine.
  • Medicare has to pay a lot more for a patient to have this than standard, but it is covered under medicare.

But this is what is so funny about this article. You are an advocate of the machine if you have one and you are not an advocate of the machine if you don’t. If you don’t have one then it costs too much, no better, and no reason to spend all that extra money for so little clinical benefits in return. It’s funny and that old adage about “three types of lies- lies, damned lies and statistics.”  Read about rectal injuries – the numbers are better for the Proton but is it “significant” particularly at the cost. Cost benefit ratio hmmmmmmmmmmmmmm. Sounding a bit like the PSA. And of course one of the doctors is from some governmental study group….wow wonder what his take will be….think National Health Care.

Any way the whole purpose of this post is to say this:

What is the difference between an environmentalist and a developer?

The environmentalist already has his cabin in the woods.

Hence if you’ve got one it’s good, If you aint’ it ain’t.

Proton cancer therapy comes at a cost

 By Robert Langreth

Imagine a prostate cancer therapy that has almost no side effects. Hospitals say it exists and they’re vying to be among the first to offer it. Too bad the treatment may not work as well as advertised and could boost America’s already spiraling health care costs.

The technology uses narrowly focused proton beams to deliver precisely targeted blasts of radiation. The particle beams are delivered by 500-ton machines in facilities that cost from $100 million to $200 million, and can require a football- field sized building to house. A typical treatment costs about $50,000, twice as much as traditional radiation therapy though it is usually covered by Medicare or private insurance.

For U.S. taxpayers and employers facing spiraling health-care costs, that’s a worry.

“Proton-beam therapy is like the death star of American medical technology; nothing so big and complicated has ever been confronted by the system,” said Amitabh Chandra, a health economist at Harvard University’s John F. Kennedy School of Government. “It’s a metaphor for all the problems we have in American medicine.”

Yet even though the machines are breathtakingly expensive, hospitals and for-profit clinics are in a race to build proton-beam facilities for their prestige, perceived benefits, and potential revenue. One machine can generate as much as $50 million in annual revenue and new facilities are sprouting up around the country.

“It’s like a nuclear arms race now, everyone wants one,” said Anthony Zietman, a radiation oncologist at Boston’s Massachusetts General Hospital, which has had a proton-beam accelerator since 2001.

Proponents of the technology say it can zap cancerous tumors without damage to surrounding tissue. That’s a major benefit for the relatively small number of people who suffer from tumors of the spine, brain and eyes, where stray radiation may blind or paralyze, or in children who are more sensitive to radiation.

The therapy has even wider appeal for treating prostate cancer, a much more common disease, since existing treatment often causes rectal bleeding as well as impotence. More than 240,000 American men were diagnosed with prostate cancer in 2011, making it the nation’s most-diagnosed tumor, according to the American Cancer Society. Most of those men are potential candidates for proton-beam therapy.

“The easiest group to market to in the country is a group of men worrying about the functioning of their penis,” said Paul Levy, former head of Beth Israel Deaconess Medical Center in Boston.

The problem is that despite the push to build proton-beam facilities and the groundswell of enthusiasm for the treatments, it remains unclear whether the therapy does a better job of shrinking tumors or avoiding side effects than the far less costly traditional therapy. Clinical trials haven’t yet provided a clear picture proving the treatment’s worth for common tumors such as prostate cancer.

Lower rates of impotence, for one, are unlikely from the use of proton therapy because proton and traditional treatments deliver high doses of radiation to the nerves to the penis, Zietman said. So whether the pricey treatments will do a better job managing prostate cancer while also preserving sexual function is an open question.

Proton-beam therapy and traditional X-rays are equally effective at killing tumor cells. The debate is over side effects. Proton-beam therapy works by shooting intense, narrow beams into targeted areas of the body. Protons slow down as they travel deep in the body. Doctors can manipulate the speed of the atomic particles, allowing them to deposit most of their radiation as they come to a stop inside a tumor.

X-rays used in conventional radiation therapy are made up of photon beams that zip through a patient, exposing tissues along the way to excess radiation. While modern machines use multiple beams sculpted to intersect and concentrate high doses on a tumor, lower doses are spread over a much larger region.

The proton technology isn’t new, but only in recent years has it caught on. Loma Linda University Medical Center in Loma Linda, Calif., built the nation’s first hospital proton-beam accelerator in 1990, but the treatment became more viable after the American Medical Association granted proton therapy an insurance billing code in 2000, making reimbursement easier, said Allan Thornton, a radiation oncologist at Hampton University’s proton-beam center, which opened in August 2010. “That brought proton therapy out of the closet,” he said.

So far, 35,000 Americans have gotten proton-beam treatment and reimbursement payments from Medicare and insurance companies amount to only a small fraction of that paid out for traditional radiation therapy.

In 2010, the most recent year for which figures are available, Medicare spent $41.8 million on outpatient proton- therapy treatments, versus $1.06 billion for standard external- beam radiation.

The amount so far reimbursed for proton-beam therapy is small because most of the 10 existing facilities have been open only a short while. Another 10 facilities are slated to open within the next few years, according to Leonard Arzt, executive director of the National Association for Proton Therapy based in Silver Spring, Maryland. Dozens more hospitals and medical centers have expressed an interest in developing their own proton-beam facilities.

Some experts are concerned that the proliferation of these centers will put yet another heavy burden on the health-care system while providing unclear benefits to most patients. “It is an example of how our health-care system is set up to become more expensive without getting necessarily better,” said Steven Pearson, president of the Institute for Clinical and Economic Review, a research institute at the Massachusetts General Hospital in Boston.

Ion Beam Applications, based in Louvain-la-Neuve, Belgium, is the leading proton-beam facility manufacturer with eight installed U.S. accelerators. Hitachi Ltd. of Tokyo and Varian Medical Systems Inc. of Palo Alto, California, are among those companies also vying for part of the U.S. market.

The Mayo Clinic is spending $370 million for systems at its campuses in Minnesota and Arizona. In San Diego, Scripps Health is working with Advanced Particle Therapy LLC, a closely held proton-beam developer, on a $220 million facility in the San Diego area that is scheduled to open in 2013 and treat 2,400 patients a year. In New York, a group of five hospitals including Memorial Sloan-Kettering Cancer Center is working on a $250 million plan to build one of the machines.

The bottom line for proton centers, said Sean Tunis, chief executive officer of the Center for Medical Technology Policy, and a former Medicare official, is that hospitals can afford to build them because they are “extremely favorably reimbursed” by Medicare and many private payers.

“The finances are favorable to put in a lot of these centers and treat a lot of prostate cancer even though there is no evidence prostate cancer is treated better with it,” he said.

A report on proton therapy done by the U.S. Agency for Healthcare Research and Quality in 2009 suggests the benefits aren’t clear. After studying 243 published articles on the therapy, the group said it found only a handful that compared proton therapy to the standard treatment, and that “no trial reported significant differences in overall or cancer-specific survival or in total serious adverse events.”

Some evidence even suggests that proton therapy may be worse than traditional radiation treatments.

A University of North Carolina study of prostate cancer patients released in February found a somewhat higher rate of bowel side effects with the new machines, and similar rates of impotence and other side effects. While not definitive, the finding may indicate the protons lose precision as they penetrate the body, said lead researcher Ronald Chen, an oncologist at the university’s Lineberger Comprehensive Cancer Center in Chapel Hill, North Carolina.

“Statements about superiority are just unjustified, they are unsupportable,” said W. Robert Lee, a radiation oncologist and prostate cancer specialist at Duke University School of Medicine in Durham, North Carolina.

Proton-beam proponents aren’t fazed by those who doubt the value of the therapy.

“Yes, there are critics, but the best minds in the cancer business think otherwise,” said Hampton University president William R. Harvey. He calls the argument that proton therapy may burden the medical system “bogus” because it doesn’t consider the potential cost savings from avoiding side effects.

Thornton, of Hampton’s proton-beam center, said that an as- yet-unpublished study he did found protons will lower rates of rectal bleeding that can occur years after radiation for prostate cancer. “The data is pretty clear,” he said.

In the analysis of 20 previous studies, Thornton and his colleagues found that 7 percent to 9 percent of prostate patients who received standard radiation experienced severe rectal effects, compared with 0.75 percent to 1.5 percent of proton patients who suffered such side effects.

Findings from some published studies show the treatment may reduce the rate of severe rectal side effects to 1 percent or less from the 2 percent to 4 percent rate seen with standard equipment, said Robert Foote, chairman of radiation oncology at the Mayo Clinic in Rochester, Minn.

“The question people are really struggling with is ‘is that worth the extra cost?’” he said. The Mayo Clinic, which is building proton systems at its Minnesota and Arizona campuses, won’t use proton therapy for routine prostate cases where less expensive treatments work well, Foote said.

Once built, hospitals and treatment centers tend to keep proton-beam facilities running night and day. The University of Florida’s proton therapy institute in Jacksonville, for instance, treats patients from 6:30 a.m. to 11 p.m., five days a week, said Stuart Klein, its executive director. It generated $45.5 million in patient care revenue in its 2009 fiscal year, according to a tax filing.

“Radiation oncologists have gotten themselves into a trap,” said Zietman of Massachusetts General. “They’ve built very expensive centers, and the only way they can recoup the costs is to treat lots of prostate cancers. A lot of men are going to be channeled into proton therapy, not necessarily to their advantage, at a very great cost.”

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i've seen it happen in other people's lives and now it's happened in mine....

So this is what it has come to. Patients are not smart enough not to “fall” for being treated for prostate cancer. So let’s change the name. One way or the other the NIH, the HHS, the USTFPF (or whatever) will figure out a way not to pay for prostate cancer screening. They are a clever bunch. And who is David Ropeik? A Harvard Public Health Guy…why you could have fooled me!

CANCER PHOBIA! Fear of the disease can do as much harm, or more, than the disease itself

David Ropeik on December 19, 2011, 9:45 AM

Fear-cancer-1If you were to be diagnosed with cancer, how do you think you would feel? It would depend on the type of cancer of course, but there’s a good chance that no matter the details, the word ‘cancer’ would make the diagnosis much more frightening. Frightening enough, in fact, to do you as much harm, or more, than the disease itself. There is no question that in many cases, we are Cancer Phobic, more afraid of the disease than the medical evidence says we need to be, and that fear alone can be bad for our health. As much as we need to understand cancer itself, we need to recognize and understand this risk, the risk of Cancer Phobia, in order to avoid all of what this awful disease can do to us.In a recent reportto the U.S. National Institutes of Health (NIH), a panel of leading experts on prostate cancer, the second most common cancer in men (after skin), said;

  • “Although most prostate cancers are slow growing and unlikely to spread, most men receive immediate treatment with surgery or radiation. These therapeutic strategies are associated with short- and long-term complications including impotence and urinary incontinence.”
  • “Approximately 10 percent of men who are eligible for observational strategies (keep an eye on it but no immediate need for surgery or radiation) choose this approach.”
  • “Early results demonstrate disease-free and survival rates that compare favorably (between observation and) curative therapy.”
  • “Because of the very favorable prognosis of low-risk prostate cancer, strong consideration should be given to removing the anxiety-provoking term ‘cancer’ for this condition.”

Let me sum that up. Many prostate cancers grow so slowly they don’t need to be treated right away…the unnecessary treatment causes significant harm…and one of the reasons nine men out of ten men diagnosed with slow-growing prostate cancer accept, indeed choose these unnecessary harms, is because “cancer” sounds scary.

Consider more evidence for Cancer Phobia. In “Overdiagnosis in Cancer” doctors at Dartmouth classified “25% of mammographically detected breast cancers, 50% of chest x-ray and/or sputum-detected lung cancers, and 60% of prostate-specific antigen–detected prostate cancers”, as ‘overdiagnosed’, which they defined as “1. The cancer never progresses (or, in fact, regresses) or 2. The cancer progresses slowly enough that the patient dies of other causes before the cancer becomes symptomatic.” The doctors described the negative health effects such patients suffer from a range of treatments that often involve radical surgery and noted; “Although such patients cannot benefit from unnecessary treatment, they can be harmed.

Beyond the harms of Cancer Phobia to individual patients, consider the cost at the societal level. The basic biological mechanics of what causes both cancer and heart disease are still inadequately understood and need fundamental research. But the NIH spend about four times as much on cancer research as on heart disease research, despite the fact that heart disease kills about 10% more people (60,000 each year, 25 per day), than cancer. We are spending far more on the second leading cause of death than we are trying to figure out what is much more likely to kill us.

Despite all the progress we’ve made on cancer, a recent Harris poll found that cancer is the most feared disease in the U.S., 41% to Alzheimer’s 31%. (Only 8% of American are most afraid of the leading cause of death in the U.S., heart disease). That is hardly new. 40 years ago the National Cancer Act of 1971, which declared “War on Cancer” said “…cancer is the disease which is the major health concern of Americans today.”

Cancer Phobia goes even further back. The term itself was coined in an article by Dr. George Crile, Jr., in Life Magazine, in 1955, “Fear of Cancer and unnecessary operations”. His insights describe conditions today as accurately as they did then; “Those responsible for telling the public about cancer have chosen the weapon of fear, believing that only through fear can the public be educated. Newspapers and magazines have magnified and spread this fear, knowing that the public is always interested in the melodramatic and the frightening. This has fostered a disease, fear of cancer, a contagious disease that spreads from mouth to ear. It is possible that today, in terms of the total number of people affected, fear of cancer is causing more suffering than cancer itself. This fear leads both doctors and patients to do unreasonable and therefore dangerous things.”

Unfortunately, Dr. Crile Jr. overlooked the key truth about our fear of cancer; Cancer Phobia is hardly just the product of zealous health and environmental advocates magnified by media alarmism. It comes from the innate way we perceive all risks, a process that relies not only the statistical and medical facts, but on how those facts feel. Risk perception is a blend of conscious reasoning and subconscious instinct, and neuroscience suggests that between the two, instincts and emotions have the upper hand. While we’ve been busy studying cancer, we have also learned a lot about the specific psychological characteristics of cancer that make it particularly frightening.

  • The more pain and suffering a risk involves, like cancer, the scarier it is.
  • The less control over a risk we feel we have, the scarier it is. Despite great medical progress, cancer is still something that too often can’t be controlled. It is still widely assumed that a diagnosis of cancer is a death sentence.
  • The more a risk feels imposed on us, rather than the result of something we did by choice, the scarier it is. Many people continue to believe that a majority of cancers are ‘done to us’ by outside forces, despite the medical evidence that environmental cancers (beyond those caused by our lifestyle choices of diet and exercise) make up perhaps 10-15% of all cases.
  • The greater our ‘mental availability’ about a risk – how readily the risk comes to mind – the scarier it is. Cancer is constantly in the news. And the very mention of the word ‘cancer’ is instantly overwhelmingly negative, a psychological effect called Stigmatization that makes it difficult for us to think about things objectively.

“Cancer” is no longer the automatic death sentence it was once feared to be. From 1990 to 2010 the overall death rate from cancer in the U.S. dropped 22% in men and 14% in women. (Incidence, the number of new cases, has stayed about the same.) We have learned an immense amount about cancer, allowing us to treat, or even prevent, some types that used to be fatal. But we have also learned a great deal about the psychology of risk perception and why our fears often don’t match the evidence. We are failing to use that knowledge to protect ourselves from the potential health risks of our innately subjective risk perception system. The proposal of the NIH panel to replace the “C” word with something else that is medically honest but emotionally less frightening, is a tiny first step in the right direction, to open a new front in the War on Cancer, the battle against Cancer Phobia.

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a friend is someone who after you’ve made a fool of yourself doesn’t feel you’ve done a permanent job.

Question: I have a 70 yo friend with a strong fam hx of prostate cancer — his father died of it.  Despite a psa of 1.2, he recently had a nodule felt by his family doctor and his urologist on dre, which was followed by a biopsy that was negative — no cancer, and nothing else unusual found.  His urologist told him yearly exams were all he needed at this point.  Would you be more aggressive?  Please explain.

The term “nodule” is used a bit broadly and even I in yesterdays video with Penelope spoke of a nodule in “broad strokes.”

  • A true palpable prostatic cancer nodule of the prostate would most commonly show cancer on biopsy.
  • It is very common for the prostate to have asymmetry and I am sure the doctor or the patient “mis-communicates” exactly what the exam revealed. I could see me telling a patient that I felt something and the patient in turn inferred “nodule.”
  • So..there are nodules or areas of firmness or asymmetry that are not because of cancer. Prostate stones are common and can give the feel of a nodule..but it’s not.
  • Chronic prostatitis and the resultant area of induration or fibrosis would feel like a cancer nodule but the biopsy would be negative and with elements of inflammation.
  • Granulomatous prostatitis does this and I have examined a gland that I was certain it was cancer only to be inflammatory changes of prostatitis.
  • The prostate can have ridges, shelves, prominent ampulla of the vas at the base of the prostate which can all masquerade as prostate cancer.
  • Benign enlargement often times is assymetrical…i.e. doesn’t feel normal but may be “physiologically” normal.

So what to do…?

In the above case the likelihood is that the palpable abnormality was something other than cancer and the negative biopsy is very encouraging. Now that we have a normal PSA, a normal biopsy and a slightly atypical exam the goal is to monitor and consider repeating a biopsy if any of the parameters change. Whether this is done on a six month basis or yearly depends on several factors to include the age and health of the patient, the anxiety mentality, and the comfort level of the urologist. In this case the patient could easily ask his family doctor to get a PSA at six months to assure that it is not changing dramatically and to provide comfort that the plan is adequately checking on things.

Remember medicine is an art not a science…so a lot of what we come up with is a blend of medicine and the interaction of the doctor and patient. I.e an anxious patient might request to be seen twice a year, the more laid back guy once a year or even asked to be returned to his family doctor.

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"Nothing is so strong as gentleness, nothing so gentle as real strength" - St. Francis de Sales

When I was a kid and grocery shopping with my mother the first place I went in the store was to the butcher department.

“May I have some bones for my dog please.” The butcher dutifully disappeared and returned with about five or six bones all wrapped up and gave them to me. Free of charge. I loved it, my dogs loved it and I thought of myself as being smart. It was great getting something useful for nothing and only because I had the courage to ask. Above Penelope is making quite the mess of our outdoor sofa with a bone that I got at the grocery but paid for. She loved it and ate every bit of it and it occupied her for about 30 minutes. I took the picture because she had two feet on the floor and two on the sofa so that she could get “good leverage” on that ole bone, that means it “were a good one.”

Don’t judge me on letting a dog eat a bone on outdoor furniture. The stain you see looks worse that it really is. Really.

A politician who had recently lost an election told a friend that he was disappointed that he had not contributed to his campaign.

The friend said, ” Well…you didn’t ask.”

What was the bible says about asking….hmmmmmmmm?


Well….just don’t do it….now where are you? Can you live with your abnormal PSA or not? Other than tissue (from a biopsy) all other things are “suggestive” of prostate cancer.

What would I tell you having done thousands of biopsies and had one myself? The risk of an infection is about 3% and the patient and doctor should have a heightened sense of awareness about fever.  If a temperture is developing then contact or get back to the urologist as soon as possible. What is probably happening is that the urologist gave you Cipro and the infection is not sensitive to it. A culture should be done quickly and a broader spectrum antibiotic given. In my office I have third generation cephlasporins available to give IM that sometimes will avert a hospitalization and used as a daily IM shot untill the culture is back. I admit about 2 people a year from infection after a biopsy and it is a frustrating situation because the bacteria is one that is not sensitive to the usual oral antibiotics and require antibiotics that can only be given by IM or IV administration.

Prostate Biopsy Risk?

Story Updated: Oct 5, 2011

In today’s health news: A danger from prostate screening that might catch guys by surprise.

Every year, millions of men have the familiar PSA test that can point to possible prostate cancer. The test is quick and simple – but it can have serious downsides.

In a new study from the Journal of Urology, researchers looked at Medicare records of men ages 65 and older who underwent a prostate biopsy. Doctors may want to do this procedure Рwhich involves taking a sample of prostate tissue Ð when a PSA test looks suspicious. They compared more than 17,000 men who had a prostate biopsy with nearly 135,000 similar men who didn’t have one.

Nearly 7 percent of the men in the biopsy group were hospitalized within 30 days, compared to just 2.9 percent of the other men. The men who went to the hospital after their biopsy had complications including bleeding and infection, as well as episodes of other problems like heart failure.

The American Cancer Society doesn’t specifically recommend that men should have the PSA test. It merely suggests that men should get familiar with the possible benefits of testing – and of course the risks – then talk to their doctor about whether testing is the right choice starting at age 45 to 50.

I’m Dr. Cindy Haines of HealthDay TV, with the news that doctors are reading; health news that matters to you.

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