Posts Tagged ‘urologist with prostate cancer’

"Do not look where you fell, but where you slipped." - African Proverb

  • No symptoms…does it matter?
  • Low PSA…does it mean no cancer?
  • Big prostate…means cancer?
  • Small prostate means no cancer?
  • Surgery better than radiation?
  • Proton better than regular “ole” radiation?
  • Age over 75-is surgery best?
  • Do you have a higher incidence of impotence with cryosurgery?
  • Why do they only do Proton on the well-mod prostate cancer in terms of the “favorability” of prostate cancer?
  • High PSA means prostate cancer?
  • You have a biopsy of your prostate cancer because of a high PSA…and it is negative…was the biopsy unnecessary?
  • Can you die of prostate cancer?
  • Can you have it before the age of 50?
  • Are all urologists the same?
  • Are all surgeons the same?
  • Will surgeons only recommend surgery?
  • What is the Gleason’s score?
  • If the guy at your church had seeds for his cancer is that the best treatment for you?
  • Are all prostate biopsies that have cancer the same?
  • Are all prostate cancers the same?
  • Does everyone that has surgery become impotent?
  • Does everyone that has radiation preserve their potency?
  • What is HIFU?
  • What is NanoKnife?
  • If you have trouble voiding does that mean you have prostate cancer?
  • When do you think the male should begin having PSAs and rectal exams?
  • Is prostate cancer hereditary?
  • Do blacks have prostate cancer more or less often than others?\
  • Does Avodart cause cancer of the prostate?
  • Can a dog smell prostate cancer in a man’s urine?
  • What is a Free PSA? How can you use it in the treatment decision-making?
  • If your friend had a particular treatment and did well, if you have the same treatment by the same doctor does that mean you will do well?
  • Is it smart to have anything other than prostate removal for prostate cancer if you are 50 or so and in good health? Hint: Think years at risk.
  • Why is years at risk, your physiologic age important in your decision?
  • What is the Partin table?
  • If there is cancer in your lymph nodes can you be cured with radiation or surgery?
  • What is the Prostatic Acid Phosphatase and how can it help you and your doctor?
  • If your Free PSA is very high indicating that you have a low likelihood of prostate cancer..does that mean you won’t have prostate cancer on biopsy?
  • Why do men get infections after a prostate biopsy?
  • What is the difference in a “autopsy evaluation of the prostate” and “twelve cores taken at the time of a prostate biopsy?”

Do you have others? I am tired for now but have probably hundred others that I will add from time to time. Comment won’t you? Mr. Cass…I bet you have a few to add.

From my book, “What was thought to be a simple disease of old men becomes after diagnosis  a potentially lethal disease with a very difficult treatment decision scenario for the newly diagnosed prostate cancer patient to consider.”

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I'm looking through you where did you go? I thought I knew you, what did I know. You don't look different but you have changed. I'm looking through you...where did you go? Rubber Soul

I don’t have to read this article. The Gleason did not change…it was there all along. When you do a biopsy and it’s all Gleason 6 and then you remove the prostate and there are elements of Gleason 7, did it change between the time of the biopsy and the subsequent removal….6 weeks? Well no, the biopsy just did not hit the Gleason 7 area. This is one of the issues with active surveillance in the healthy young, you are making decisions based on a “tiny” sampling of the prostate. Are you listening Clark Howard?

Gleason Grade Often Changes During Active Prostate Surveillance



By Dave Levitan

NEW YORK (Reuters Health) Jun 01 – Changes in Gleason score are common during active surveillance for prostate cancer, a new paper says.

About 25% of such men will have subsequent negative biopsies and about 35% will have an upgrade, said lead author Dr. Sima Porten of the University of California, San Francisco, in an e-mail to Reuters Health.

Until now, not much was known about biopsy changes in men who opt for active surveillance, Dr. Porten and colleagues write in their report, published online May 31 in the Journal of Clinical Oncology.

The new study involved 377 men undergoing active surveillance. Ninety-four percent had an initial Gleason score of 6 or less, and 6% had a score of 7 (either 3 + 4 or 4+3).

The mean time to follow-up after the initial biopsy was 54 months. At the first repeat biopsy, 81 men (21%) had an upgraded Gleason score; 91 (24%) had a negative finding, 198 (53%) had no change, and seven men (2%) were downgraded.

Of the 198 with no change after the second biopsy, only 24 were upgraded after a third. Of the 69 men who showed no change until a fourth biopsy, six men then experienced an upgrade. Nearly all the men who had progression on biopsy — 98% — were upgraded to Gleason 3 + 4 disease.

Of the 91 who had a negative second biopsy, 19 (21%) had a positive finding on a third biopsy. Thirteen  of 43 (30%) had cancer discovered on a fourth biopsy.

Fifty-nine percent of men with upgraded score opted for definitive treatment, though the authors noted they haven’t been following the men long enough to make definitive statements on treatment outcomes. Still, Dr. Porten suggests that early data indicate there may be little difference between immediate and delayed treatment.

“In individual patients, biopsy changes are fairly variable over time, but overall, men who experience an upgrade and go on to subsequent treatment have favorable outcomes and seem to be no different than those who are treated outright,” Dr. Porten said.

SOURCE: http://bit.ly/liGZW9

J Clin Oncol 2011.

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don't put off today for tomorrow...tomorrow has its own problems



Clarion ForeW0rd Five Star Review of “The Decision.”    

 Not too shabby!


The Decision: Your prostate biopsy shows cancer. Now What?
John C. McHugh



Five Stars (out of Five)

There is very little that is more startling than getting a call from a doctor with the news that the
diagnosis is cancer. A recent article indicated that 200,
000 men are diagnosed with prostate
cancer in the United States every year; 25,000 die of the disease. Dr. John C.
McHugh, an
experienced urologist and surgeon, brings a rational, no-
nonsense approach to the decision
regarding treatment for prostate cancer in The Decision: Your prostate biopsy shows cance
Now What? McHugh knows of what he speaks: Not only has he couns
eled men with prostate
cancer in his urology practice for more than 25 years,
but he himself was diagnosed with the
disease at age 52 and experienced the gut-wrenching decision that is the subject of his book.

Importantly, Dr. McHugh does not overwhelm the reader with too much information. He
is writing for the man who already has been diagnosed with prostate cancer. “Right now,
don’t need a big, comprehensive book about the causes and intricacies of prostate cancer;
that is
irrelevant to you.” What a man at this point needs is specific information about hi
s options for
treatment that is relevant to his particular circumstances.

According to McHugh, the man diagnosed with prostate cancer needs to know about his
cancer, his general underlying health condition, and the best treatment options available to him.
While the author is a urological surgeon,
he is not biased toward a surgical solution. He
recognizes that there are valid reasons for choosing other options for treatment,
such as radiation
and seed implantation. McHugh gives a detailed discussion of the pros and cons of each mode of

treatment in language easily understood by the layman. Along the way, the author relays various
experiences he and others have had in the course of selecting a treatment.

Significantly, the author describes and discusses the various side effects of each of the
treatment options he lists: surgery, radiation and seed implantation. Considering only the
treatment procedure without its attendant side effects is only half an analysis, he believes.
radiation treatment is quick and easily administered and allows the patient to return to
work sooner than surgery.
But radiation can also complicate pre-existing voiding problems and
may have longer lasting and uncertain detrimental effects.

McHugh has written an invaluable tool for the man facing the decision of how to treat his
prostate cancer.

This reviewer too knows of what he speaks, having been diagnosed with prostate cancer
nearly six years ago. He had robotic surgery and is living an active, cancer-free life.

John Michael Senger


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he who knows his enemy and himself always wins, he who knows himself and not the enemy sometimes wins, he who knows neither himself or his enemy always loses

 It was pretty today in Northeast Georgia….a bit windy however.

My newest stab at podcasting…what do you think? My plan is to take about 100 specific questions about prostate cancer ( I cheat by looking at my blog’s search history) and answer them concisely and hopefully with a somewhat clever and irreverant slant. Today I figured out the microphone and the garage band software on the iMac…need to work  on how to let Quicktime play and avi file.

Podbean Podcast Prostate Cancer Diaries Minute

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

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

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

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

Used Cars and Mr. Squarf

Mr. Squarf-Fool or Guru?

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

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

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

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

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

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

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

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the only risk is not taking risk.....that's how i used to feel....

Fat…the mud of surgery.

When I was a resident in urology at the V.A. in Augusta, Georgia I had done a biopsy on a patient that showed cancer. The patient was sitting on an exam table as I stepped out to make my case to the attending physician to do a radical prostatectomy on him. The patient fit all the criteria for surgery save one thing. He was very much over weight and carried all of it right over where you’d make the incision (a vertical suprapubic incision.) So…I make my case and the attending wants to meet and interview the patient. I open the door with the attending behind me and we both are met with the side view silhouette of the patient prominently displaying his large belly. Before I can speak or introduce the attending, he reaches around me and pulls the door closed. Out in the hall outside the patients exam room the attending says to me matter of factly,” No way in hell John.” And then walked away.

Comments made about my book are interesting to me. One was recently placed on Amazon and the author rated my book as a 3 (good but not great). The complaint had to do with his feeling that I was biased toward surgery. The review was actually quite good and thorough and it was obvious that he was an informed patient. I am impressed by what I have read by men who really have researched this disease, as you have seen just last week one person corrected an error I made in regards to PIN. I had used the wrong word for the I. ( I remembered it as intranuclear and it was actually intraepithelial.)

So…Am I as a urologist biased toward surgery? Several points and this will also give you some insight in the mind of a surgeon in general and a urologist in particular.

  • In my book I said that I was biased toward surgery but only in certain circumstances. I chose surgery because of my age, my biopsy specifics , the fact that I knew the potential complications and was at peace with that, and that I feel it is a “cleaner” treatment. Now…that’s for me.
  • I don’t think surgery is a good option for someone with a phobia about incontinence.
  • Not good if you have other medical problems that are moderately severe.
  • If you are overweight with a protuberant abdomen- (the robot somewhat neutralizes this concern)
  • If you can’t miss work.
  • If you have a family member that needs you to be of help to them.
  • Your life expectancy is less than what we would anticipate from the specifics of your prostate biopsy.
  • You don’t want surgery.
  • You have very favorable parameters and want to the best treatment with least down time.
  • If you are over 75  I wouldn’t recommend surgery.
  • If you are over 65 and in poor health.

This will sound tricky but in the very best scenario no complications (can’t guarantee that) and alls well after the treatment and you compare the treatments….I feel surgery is better. Why? No cancer, no incontinence, no impotence…both the same right, both equal?

Well…the radiation guy has radiation in his body and this comes with consequences down the road. Other surgeries, other potential cancers from the radiation. Patients forget (or not told or did not hear) that the side effects of radiation occur sometimes years after it is given. Or the options of intrabdominal surgery may be hampered by having had radiation. All of these issues however don’t matter if you are not a candidate for surgery, you don’t want surgery, and you value the fact that you’d rather have irritative voiding symptoms of radiation than the potential stress incontinence symptoms of surgery.

So I am biased for surgery if you are the right patient, with the right path report, and the right frame of mind.

I am not biased for surgery if you are not the right candidate, if you don’t want it or if “you” are biased against surgery.

My job is to state the facts as I see them and aid my patients to the decision which they feel is best for them.

As to the review and being graded low for speaking more to the side effects of radiation than to surgery…here’s the deal on that.

Most patients know very well the risks with surgery. They don’t however know as well the short and long-term side effects of radiation. I do believe I did spent a lot of time on this issue…particularly as it pertains to how one voids after radiation if they had an enlarged prostate before the radiation.

As a radiation therapist friend of my told me about the options about treatments, “John there ain’t no free ride.” The trick is matching the patient to the disease and the treatment.

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