Posts Tagged ‘the decision about prostate cancer’

men are not prisoners of fate…they are prisoners of their own minds…..FDR- that’s a 1966 Ford Mustang-289-original body style


John…nothing you drive has an airbag…a lot of people depend on you…buy a new car!


The Five Reasons:

  1. You don’t have radiation in your body the rest of your life.
  2. You don’t have radiation in your body the rest of your life.
  3. You don’t have radiation in your body the rest of your life.
  4. You don’t have radiation in your body the rest of your life.
  5. You don’t have radiation in your body the rest of your life.


Tomorrow: Five reasons not to have your prostate removed…see…I am not biased, I am not biased, I am not biased…


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

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

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

“A little knowledge is a dangerous thing.”

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

An interesting question on Podbean

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if you want to know what a man is thinking or why he is acting the way he does.....go around behind him...and look out at what he is looking at.....paraphrased will rogers....one of my favorites

One of my heroes of all time is Will Rogers. If you have not read a book about him….do it. He is the best. He was a Rush Limbaugh of sorts in the early 1900’s. My son, Sam is an Eagle Scout, and he and I hiked for two weeks in New Mexico at Philmont. Waite Phillips donated the land to the scouts many years ago and as such “doing Philmont” is a rite of passage so to speak in scouting. Phillips made his money in oil and was one of the first men to utilize the concept of a “gas station.” Phillips 66 doted Route 66 in its heyday. We went to Waite Phillips house near the beginning point of the house and in the basement was a picture of Waite Phillips and Will Rogers. Rogers had stopped off at Phillip’s place 0n his way to somewhere else.I would like to think that I am a kindred spirit with Will Rogers. He died in a plane crash with Wiley Post at a far away place in Alaska. In his pocket it is reported that he had a lucky wooden nickel, and a set of jacks. I get it.

By the way…in the news this week was a story about how a video of college students having sex on a rooftop at USC going viral. Guess what the building’s name was? Waite Phillips Hall.

Many of you reading this are thinking or Roy Rogers…I am speaking of Will. I have read several books about him and even went to New York to see “Will Roger Follies.” He began his career as a cowboy and had a talent of playing with ropes and making them do tricks, a rope lariat, not poet lariat. He traveled about and as I recall he got on a boat with a circus and refined his lariat skills. He made his way to New York was in Zigfeld Follies. So finally I am to the point I want to tell.

When Roger’s performed he did not talk. He just did rope tricks and did that for hundreds of performances. One day he messed up a trick and the rope fell to the ground not in keeping with the intended trick. He looked up and said, ” I guess I can’t do rope tricks and chew gum at the same time.” He walked over to side of the stage and took the gum out of his mouth and stuck it on the wall. The audience roared in laughter. It was such a hit that he decided he’d drop the rope and mess up the trick on purpose so that he could use the line again. With each successive show he added more lines and in time his show was more talking than roping.

Then he became his own show. He’d have a newspaper and he’d read a story and then comment on it in an informative yet funny way. Rogers quotes are now well-known and timeless. “All I know, I’ve read in a newspaper.” “I am of  no particular or organized party…I am a democrat.” Being from North Georgia and home of moonshining and stills, I like this one, “Nothing helped improve the roads in America like prohibition did.” Think Dawsonville’s Bill Elliott.

He had a daily spot in the newspaper with just a short thought or comment. Again….Rush Limbaugh has used his technique. Read a story, or play a sound bite of stuff that is reported and then comment on it in a funny way. Rogers became the highest paid performer in america. He was an advocate of commercial air travel and his travelling by plane did more to promote the public’s acceptance of it as being safe..somewhat ironic seeing how he died in a plane. But that is a whole nother story. Wiley Post.”Let’s go flying Will!”

My mother loved telling this on Will Rogers and she loved telling me to be “big about it.” This is where the following came from. Will Rogers would be asked to be the featured performer at Presidential functions. Numerous presidents  from both parties had him as a performer. He’d go and make fun of them and their party in a clever way. Someone asked him one time how was it that the most powerful men in the world would invite someone who they knew would be making fun of them and their policies. He replied….” Because…they are big people.”

So. When I was summoned to retrieve my son Sam from the University of Oklahoma and drive him and his car back from there to Georgia, I was delightfully surprised to end up in front of my hero…Will Rogers and the Will Rogers International Airport. An airport that did not have my baggage from Atlanta. No problem. I got it the next day. My son was an issue as well. ” Dad. Can’t come pick you just yet. My battery is dead in my car. I am working on borrowing a car. I’ll let you know. I’ll call.”

No baggage, nobody there to  pick  me up, but I was in Oklahoma with a statue of Will Rogers. Really….I wasn’t working….It could be said that, ” It don’t get no better that this.”

Now it is a beautiful Sunday afternoon in Northeast Georgia and my wife is at the beach with my daughter Bess. I am “home alone” and that really is not good. I like being alone for about 23 hours then I don’t like it. I thought I’d like it, but then I miss all that my wife” brings to the table.” I have the dogs and “their” issues to deal with. Then it came to me. My son, Sam, who is in Savannah, let me borrow  his friend’s mother’s Flip, and it dawns on me that I could do an Amazon video for Author Central using the friend’s mother’s Flip…and I do it. So…..without further a deau…..is that the way you say or spell that….it’s okay…I am from the south and we southerner’s don’t know the sophisticated ways of the north…..and bla bla bla

Oh I forgot…surveillance. I just finished one of the requirements for the Board of Urology, it’s called MOC, or maintenance of certification. I had several disease options to choose from and you guessed it…I chose prostate cancer. The whole thing, and obviously what the board members thought was important to its member urologists, was about being sure that all the options for the treatment of prostate are given to the patient along with the risks and benefits of each. Active surveillance was listed as one of the treatment options to be offered and documented as having been discussed. (This should make those of you who think that all surgeons want to do is remove your prostate feel maybe a little bit better.)

I mention in my book that active surveillance is a bit dicey for the guy less than 60 and it is an option for a certain type of mindset. An anxious person will not go this route. I personally considered it but my mind wasn’t good with it. I had a guy “give in” to doing something (abandoned surveillance) because he knew did not want radiation and if  the disease progressed, he’d rather deal with surgery at his current age than 3-5 years down the road.

In my practice for my patients that choose surveillance, I do what they do at Johns Hopkins and that is a PSA twice a year and a biopsy yearly. The patients that I follow this way are very pleased and usually feel very comfortable with their decision.

I spent way too long on this post…but when I saw the picture of Will Rogers with Waite Phillips in the basement of Phillips’ home at Philmont and I had been hiking with kids for two weeks straight…well it did me good to remember all that and how it felt to be done and to think I was standing in a place where Rogers once was as a guest. History does me that way. It intriques me but frustrates me…I want to feel it but it is a tease…and that keeps me reading.

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it is amazing what can be accomplished if it doesn't matter who gets the credit


So…A dream I had as a child was a pool with a lap lane. I love to swim and when I  was younger , I was actually quite the swimmer. I rarely lost a race in any stroke. There was a boy in Columbus, Georgia who regularly beat me…but no one else. I ruled the swimming world when I was eight in Columbus, Georgia. I remember winning every event in every stroke at the Green Island Country Club on a day when there was a total eclipse. We were swimming and at the same time looking at these tin foil card board boxes that allowed one to see the eclipse without looking directly into the sun. I remember it as if it were yesterday.

So, I get to be a doctor, I chose to be a urologist and then with some success, I get to build a new house with a swimming pool with a lap lane. My dream come true…right? Well…. what if the pool turns out to look like a penis? What?  All these years and hopes and dreams and a pool that looks like a penis?  Tell me it isn’t so.

It was. A regular oblong pool with a lap lane looks like a penis and a scrotum.  We also had two dachshunds and so I became the urologist with a dick pool and two weinner dogs. Who’d thought? My kids got ribbed about it all the time. I thought I was successful but now this?

I will say I love my pool. I love my chocolate lab chasing balls and sticks in it. I love taking pictures of her chasing balls and sticks in it and swimming in it. I absolutely love my lab in the pool.

Now the question. Can a man with prostate cancer “spread something” to his wife by having sex?


So….good try girls….be more creative next time…you are not getting out of it for this reason or this time…………….have at it.

Guys…You are welcome….no charge.

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management is doing things right, leadership is doing the right things....peter drucker

Recent comment/question on this blog

I recently had a PSA of 17 and so saw a urologist and he ordered antibiotics for a month and another test. Tested the same and so he performed a biopsy with the 12 small cores you mentioned. Biopsy came back negative for cancer. I should mention there have been no symptoms, no urination problems, nothing at all which I have read is very common.

My urologist has recommended another biopsy in 6 months. My thought is to have another PSA check in 6 months and if PSA is the same avoid the second biopsy until and if I ever see an increase from 17. What do you think? From What I have read the biopsy should be avoided unless necessary.


This question comes up often and is troublesome for both the patient and the urologist. Here are some salient points to consider. Also view this issue as if you are the patient (who doesn’t want to be prodded unnecessarily) and as the urologist( who doesn’t want to be sued for not diagnosing a prostate cancer in the face of a markedly abnormal PSA):

  • There is no real harm to having multiple  biopsies of the prostate. No evidence that it spreads cancer, and the risk of infection or bleeding is the same each time not increased.
  • In my career I have diagnosed prostate cancer after two negative biopsies only a smattering of times. Only once was the cancer of an aggressive nature ie. Gleason’s 8.
  • If you have had one prostate biopsy and it was negative that is a good thing on two fronts. One on cancer was found, and if you are found to have prostate cancer on a subsequent biopsy it is usually small volume and low Gleason’s.
  • If you have a high PSA, it is an abnormal value, that must be followed. Whether you proceed with a second or third biopsy is a decision that is reached with input from both the doctor and the patient. Remember , “no one can make you do nothing.”
  • The chances of finding cancer decreases with each successive  biopsy.
  • Today I diagnosed a small volume low Gleason’s on a fourth biopsy and a PSA of 20. The 20 PSA is probably unrelated to the small amount of cancer found. But what were we to do? 


So what would I recommend for the patient and the above question. A lot of what will be done will be determined by the mindset of patient. The anxious patient will wholeheartedly want to have another biopsy. The patient who is pleased with the current result and reluctant to have another biopsy (due to fear, mistrust, the cost, the pain) and this outweighs his concerns about cancer-won’t have another biopsy.

Now my recommendation for this patient: I feel that another biopsy would give peace of mind to the doctor and the patient and would recommend another biopsy…at some point. I’d repeat the PSA at the next visit to be sure it is still elevated (PSA’s are notorious for changing up or down.) If the second biopsy is negative, I’d only repeat another one if the PSA changed dramatically, ie-maybe from the 17 to mid twenties.

Something to remember, a biopsy is usually twelve cores and that samples a very small portion of the prostate.

I did a biopsy yesterday, the fourth the guy has had over 10 years, because his PSA went from 25 to 50. The biopsy was negative.

In conclusion, the decision to have another biopsy for an elevated PSA is tricky and depends  a lot on the personality and mentality of the patient.  The urologist in general being “risk averse” will always offer the suggestion of a “re sampling of the prostate” because if he does not and the patient ultimately has prostate cancer, he rightfully could be at risk legally.

I would do another biopsy in this case if the PSA is still in the 17 or higher range and then be hesitant to do another one unless dramatic changes. If I recommended a biopsy and the patient says no, that is fine with me. I simply dictate that the patient declined the test and then I work out with the patient the parameters by which he is comfortable that would prompt another biopsy. For instance, in this case we do exactly what this patients wants. No biopsy unless big changes. We discuss the options, pros and cons, and move forward together. No need for another urologist, an honest well thought out plan vetted through the prism of the urologist who does this type of thing on a daily basis.

About “avoided unless necessary” that’s tricky too. If you do a breast biopsy for a palpable nodule and it is negative…was the biopsy necessary?  The problem with this case is that you have a PSA that is four times normal and in the back of the mind of those concerned is the possibility (we don’t know how great) that there is an undiagnosed prostate cancer that may have elements of Gleason 7 or 8. I have been repeating biopsies in this scenario with attention to the anterior portion of the prostate and taking a few samples of that area.

It’s tricky but a solution can be reached by a patient  and a urologist willing to work together and vet each other’s concerns.

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you will never get ahead if you spend your time trying to get even....lou holtz

The stats helper monkeys at WordPress.com mulled over how this blog did in 2010, and here’s a high level summary of its overall blog health:

Healthy blog!

The Blog-Health-o-Meter™ reads Wow.

Crunchy numbers

Featured image

About 3 million people visit the Taj Mahal every year. This blog was viewed about 42,000 times in 2010. If it were the Taj Mahal, it would take about 5 days for that many people to see it.

In 2010, there were 242 new posts, not bad for the first year! There were 251 pictures uploaded, taking up a total of 251mb. That’s about 5 pictures per week.

The busiest day of the year was October 8th with 319 views. The most popular post that day was How I as a urologist made my “Decision.”.

Where did they come from?

The top referring sites in 2010 were yananow.net, mail.yahoo.com, theprostatedecision.com, twitter.com, and search.aol.com.

Some visitors came searching, mostly for prostate cancer diaries, prostate diaries, frank zappa prostate cancer, bill clinton cancer, and alberto sabatino.

Attractions in 2010

These are the posts and pages that got the most views in 2010.


How I as a urologist made my “Decision.” September 2010


“Decision” Process February 2010


Prostate Diaries January 2010


McHugh Decision Worksheet February 2010
1 comment


McHugh Decision Cheat Sheet-It is imperative that you understand and have considered each of the questions in order to make the “Right Decision” for you. February 2010

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I must confess I don't believe in time- Nabokov

Doug Gray’s book regarding “For” or “Against” Screening (Uh Oh….that means a PSA!)

Resources from HONselect

PSA Test Does Cut Prostate Cancer Deaths, Study Finds

Swedish report adds to controversy over the usefulness of the blood screen

By Steven Reinberg

HealthDay Reporter

WEDNESDAY, June 30 (HealthDay News) — Adding to the ongoing debate on the usefulness of the prostate-specific antigen (PSA) blood test for prostate cancer, new research from Sweden finds the screen cuts lives lost to the disease by almost half.

The argument over whether PSA screening saves men’s lives or merely leads to the overdiagnosis of very slow-growing cancers (with attendant worry and overtreatment) has bedeviled the medical world for years.

According to recently revised guidelines from the American Cancer Society, men at average risk for prostate cancer should discuss the PSA test with their doctor, starting at age 50. For men at high risk for the disease — blacks and men who have a father, brother or son found to have prostate cancer at an early age (before 65) — that discussion should start at age 45.

“Because prostate cancer grows slowly, those men without symptoms of prostate cancer who do not have a 10-year life expectancy should not be offered testing since they are not likely to benefit,” the society notes on its Web site.

Ambivalence over the test hasn’t been confined to the United States.

“In Europe, we have been reluctant to recommend that all men get PSA testing as we have felt that there has been a lack of knowledge,” agreed lead researcher Dr. Jonas Hugosson, a professor of urology at the University of Gothenburg.

However, he believes that with the results of the new 14-year study, “it feels ethically difficult not at least to inform all men over the age of 50 about PSA and its possibilities. Personally, I would recommend my friends check their PSA,” Hugosson added.

The report is published in the June 30 online edition of The Lancet Oncology.

For the still-ongoing study, Hugosson randomly assigned some 20,000 men to either PSA screening once every two years or no screening. The men were between 50 and 65 at the start of the study.

Men whose PSA levels were above normal were offered more tests, such as a digital rectal exam and prostate biopsies.

Over 14 years of follow-up, deaths from prostate cancer dropped by 44 percent among the screened men, compared with unscreened men, the researchers found. Overall, 44 of the men who had PSA testing died from prostate cancer, compared to 78 men who had not had been screened.

Among screened men, 11.4 percent were diagnosed with prostate cancer, compared with 7.2 percent of unscreened men. Of the men in the screened group diagnosed with prostate cancer, nearly 79 percent were diagnosed because they took part in the study, the researchers noted.

In addition, men in the screened group were more likely to have their cancer diagnosed while it was in an early stage. In the screened group, 46 men were diagnosed with advanced cancer, compared with 87 men in the unscreened group, Hugosson’s team found.

“Our study has a longer follow-up than previous studies, but shows that in those men invited [to the study], the risk of dying is only half of that in the control group. In men younger than 60 at study entry, the effect was even more pronounced — only one-quarter of expected deaths occurred,” Hugosson said.

Moreover, the risk of over-diagnosis was less than previously thought, with just 12 men needed to be diagnosed to save one life. However, since the benefit of PSA screening requires at least 10 years to be borne out, it still seems questionable to test PSA for men over 70, the researchers noted.

Dr. David E. Neal, a professor of surgical oncology at the University of Cambridge in the U.K. and author of an accompanying editorial, believes that, “PSA testing detects prostate cancer early in its natural history when it causes no symptoms. By doing so, it can save the lives of some men who would otherwise have died of the disease.”

This study adds to previous evidence that PSA testing and screening for prostate cancer saves lives, he said. Still, the PSA test remains “a blunt instrument,” when it comes to determining the aggressiveness of a particular tumor, Neal said. “We need better tests that identify more accurately those men destined to develop problems in the future from this disease,” he said.

In the United States, PSA testing remains a routine part of most physical exams, according to Dr. Nelson Neal Stone, a professor of urology and radiation oncology at the Mount Sinai School of Medicine in New York City.

“I would say 70 to 80 percent of physicians now order a PSA test,” he said. “So it is more or less the standard to care in America to get a PSA done.”

Stone noted that screening detects a lot of early cancers, which do not need to be treated. “When we see patients with low-risk disease we don’t treat them, we observe them,” he said.

“Younger men benefit most from screening, because they have the greatest risk of dying,” Stone said. “This study clearly supports PSA screening to prevent prostate cancer deaths.”

Another expert, Dr. Anthony D’Amico, chief of radiation oncology at Brigham and Women’s Hospital in Boston, added that “people in good health will benefit from [PSA] screening, but people in poor health may not benefit at all.” That’s because if their prostate tumor is not aggressive they are more likely to die from the other, more serious conditions, he explained.

More information

For more information on prostate cancer, visit the American Cancer Society.

SOURCES: Jonas Hugosson, M.D., Ph.D., professor, urology, University of Gothenburg, Sweden; David E Neal, M.B., professor, surgical oncology, University of Cambridge, U.K.; Anthony D’Amico, M.D., Ph.D, chief, radiation oncology, Brigham and Women’s Hospital, Boston; Nelson Neal Stone, M.D., professor, urology and radiation oncology, Mount Sinai School of Medicine, New York City; June 30, 2010, The Lancet Oncology


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