PSA Testing -To Screen Or Not to Screen-What the Experts are Saying

Prostate cancer is the most common non-skin cancer in men with 250,000 new cases every year. The disease can be detected by screening with a PSA blood test and a digital rectal exam. Some men with prostate cancer will go on to treatment and are at risk for complications including impotence or erectile dysfunction and urinary incontinence or leaking urine.
The American Urologic Association has just released new guidelines for prostate cancer screening that I would like to share with you and hope that you can use this information to make a decision if prostate cancer screening is appropriate for you.

Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. In this age group there is a low prevalence of clinically detectable prostate cancer, no evidence demonstrating benefit of screening and likely the same harms of screening as in other age groups.

Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk, i.e., those men who do not have a family member with prostate cancer or men of African American race. For men younger than age 55 years at higher risk (e.g. positive family history or African American race), decisions regarding prostate cancer screening should be individualized.

Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making between doctor and patient for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences. The greatest benefit of screening appears to be in men ages 55 to 69 years.

Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives. Additionally, intervals for rescreening can be individualized by a baseline PSA level.

Guideline Statement 5: The Panel does not recommend routine PSA screening in men over age 70 years or any man with less than a 10 to 15 year life expectancy.
Some men over age 70 years who are in excellent health may benefit from prostate cancer screening.

Bottom Line: I think not to screen men at all is probably not a good idea. However, in selected men, the decision not to screen is probably a good one. I do believe that men need to have a discussion with their doctors and decide on a case by case basis whether or not to screen for prostate cancer using the PSA test.

Screening For Prostate Cancer-New Guidelines and One Doctor’s Advice

Prostate cancer is the most commonly diagnosed non–skin cancer among U.S. men. It can be life-threatening, and many men have cancer without knowing it. For those reasons, doctors sometimes look for prostate cancer in healthy men (screen for cancer) by measuring blood levels of prostate-specific antigen (PSA), a protein secreted by the prostate gland. High PSA levels can be caused by cancer and may lead a doctor to take a sample of prostate tissue to see whether cancer is present (biopsy). Most prostate cancer grows very slowly, however, and many men with prostate cancer die of other causes. Neither PSA testing nor prostate biopsy tells doctors with certainty which cases of prostate cancer are threatening and which require treatment. As a result, many men with slow-growing cancer have biopsies and treatment after PSA testing that they would not have needed if doctors had never tested them.

The value of the PSA test has recently come into question, however, with several studies suggesting it causes men more harm than good — spotting too many slow-growing tumors that, especially in older patients, may never lead to serious illness or death. In 2012, the U.S. Preventive Services Task Force, an influential government-appointed panel, advised against any routine use of the PSA test for prostate cancer in all men.

Since most urologists consider the Task Force’s guidelines and global ban on PSA testing far too stringent For that reason, a group of experts at the recent 2013 American Urologic Association’s annual meeting in San Diego recently recommended against annual testing and prostate biopsies at certain PSA levels, usually a level greater than 4.0ng\ml. It is possible that using the PSA test differently (for example, by testing less often) would still be useful but reduce the harms of unnecessary treatment such as urinary incontinence and erectile dysfunction that come from more frequent testing.

What are the new AUA recommendations? There are several ways of using the PSA test to help men make the diagnosis of prostate cancer while reducing the harms of testing. The first way is to stop screening after age 70 years because men older than 70 years tend to have higher PSA levels without having prostate cancer, or if they have cancer, it is usually the slow-growing variety and does not result in a cause of older men’s mortality. Another way to use the new guidelines included measuring PSA levels less frequently such as every two years in men whose levels are normal especially when the initial PSA levels are less than 1.0ng\ml. Finally, the doctor caring for older men might recommend that they have higher levels of PSA before recommending a biopsy and possible unnecessary treatment.

It is hoped that the new recommendations by the American Urologic Association will result in more personalized health management where discussions will take place between doctor and patient and where the risk of having prostate cancer and the age of the man are balanced against the value of screening.
The new AUA guidelines are more nuanced. The group does recommend against the PSA test for men under age 40 or for those aged 40 to 54 at average risk for prostate cancer.

The AUA says, however, that men aged 55 to 69 should talk to their doctors about the risks and benefits of PSA screening and make a decision based on their personal values and preferences.

Routine PSA screening is not recommended for men over age 70 or any man with less than a 10- to 15-year life expectancy.

The best evidence of benefit from PSA screening was among men aged 55 to 69 screened every two to four years. In this group, PSA testing was found to prevent one death a decade for every 1,000 men screened. The guidelines also said PSA screening could benefit men in other age groups who are at higher risk of prostate cancer due to factors such as race, i.e., African American men and men with family history of prostate cancer. These men should discuss their risk with a doctor and assess the benefits and potential harms of PSA testing.

Bottom Line: What do I recommend that you tell patients? I agree with the guidelines that men over age 70 probably do not need to be tested. Also men younger than age 50 do not need to be tested. The exception is African American men and men with a family history of prostate cancer. I would not test a man with multiple chronic conditions, which would decrease his life expectancy to less than 10 years. I would also suggest that men with very low PSA levels, i.e., less than 1.0ng\ml, be tested every two years.

Finally, the discussions between a patient and his doctor on the PSA test are extremely important. I suggest you ask the man if he gets a PSA test, would he submit to a prostate biopsy and if he has prostate cancer would he accept treatment for the condition? If the answer is no, then I would document this in the chart and not obtain the test.

Worried About Prostate Cancer? Then Get Moving

Prostate cancer affects 250,000 men every year and is the second most common cause of death in men following lung cancer. If you have a relative with prostate cancer such as a father, brother, uncle or cousin and\or you are African American, you have a greater risk of developing prostate cancer. The diagnosis is made by a digital rectal exam and a prostate specific antigen or PSA blood test.

A report from the May Clinic (2013;88:11-21) pointed out that men who lead a sedentary life style or who have low levels of physical activity are more likely to have an elevated PSA test. For each hour increase in physical exercise, men are nearly 20% less likely to have an elevated PSA test.

Regular physical activity may reduce prostate cancer risk through changes in energy balance, enhanced immune function, decrease in inflammation, and an increase in anti-oxidant defenses.

Bottom Line: No one knows what exactly causes prostate cancer but it is possible that an increase in physical activity may decrease the PSA level and possibly decrease the risk of prostate cancer.

Eating and Exercising Your Way To Prostate Health and Preserving Your Potency

Location of prostate gland at the base of the bladder and surrounding the urethra

I am frequently asked by my patients “What can I eat to reduce my risk of developing prostate cancer?” This is one of the most common questions I am asked by men concerned about prostate health. Undoubtedly, many hope that their doctor will rattle off a list of foods guaranteed to shield them from disease. Although some foods have been linked with reduced risk of prostate cancer, proof that they really work is lacking, at least for now.
Aim for a healthy eating pattern
Instead of focusing on specific foods, dietitians, physicians, and researchers tout an overall pattern of healthy eating — and healthy eating is easier than you might think. In a nutshell, here’s what experts recommend:
1. Eat at least five servings of fruits and vegetables every day. Go for those with deep, bright color.
2. Choose whole-grain bread instead of white bread, and choose whole-grain pasta and cereals.
3. Limit your consumption of red meat, including beef, pork, lamb, and goat, and processed meats, such as bologna and hot dogs. Fish, skinless poultry, beans, and eggs are healthier sources of protein.
4. Choose healthful fats, such as olive oil, nuts (almonds, walnuts, pecans), and avocados. Limit saturated fats from dairy and other animal products. Avoid partially hydrogenated fats (trans fats), which are in many fast foods and packaged foods.
5. Avoid sugar-sweetened drinks, such as sodas and many fruit juices. Eat sweets as an occasional treat.
6. Cut down on salt. Choose foods low in sodium by reading and comparing food labels. Limit the use of canned, processed, and frozen foods.
7. Watch portion sizes. Eat slowly, and stop eating when you are full. One of my best suggestions that I have tried to adopt is to eat my entre from a smaller salad plate which makes the portion look bigger. Also, try eating with your non-dominate hand as this will slow down your eating. Finally, after you eat your first portion, wait 10-15 minutes before taking a second portion. This allows your brain to catch up with your stomach and will give you a feeling of satiety without overeating.

Stay active
In addition to eating a healthy diet, you should stay active. Regular exercise pares down your risk of developing some deadly problems, including heart disease, stroke, and certain types of cancer. And although relatively few studies have directly assessed the impact of exercise on prostate health, those that have been done have concluded, for the most part, that exercise is beneficial. For example:
1. Based on questionnaires completed by more than 30,000 men in the Health Professionals Follow-up Study, researchers found an inverse relationship between physical activity and BPH symptoms. Simply put, men who were more physically active were less likely to suffer from BPH. Even low- to moderate-intensity physical activity, such as walking regularly at a moderate pace, yielded benefits.
2. Using data from the Health Professionals Follow-up Study, researchers also examined the relationship between erectile dysfunction (ED) and exercise. They found that men who ran for an hour and a half or did three hours of rigorous outdoor work per week were 20% less likely to develop ED than those who didn’t exercise at all. More physical activity conferred a greater benefit. Interestingly, regardless of the level of exercise, men who were overweight or obese had a greater risk of ED than men with an ideal body mass index, or BMI.
Italian researchers randomly assigned 231 sedentary men with chronic prostatitis to one of two exercise programs for 18 weeks: aerobic exercise, which included brisk walking, or nonaerobic exercise, which included leg lifts, sit-ups, and stretching. Each group exercised three times a week. At the end of the trial, men in both groups felt better, but those in the aerobic exercise group experienced significantly greater improvements in prostatitis pain, anxiety and depression, and quality of life.

Bottom Line: There’s not much you can do about your genetics or what you inherited from your parents. But there’s a lot you can do by eating healthy and exercising regularly. Your prostate gland will thank you.

This article was modified from an article appearing in The Harvard HealthBeat on October 4, 2011 http://www.HarvardProstateKnowledge.org.

Fried Red Meat-It May Be Dangerous For Your Prostate Gland

Fried steak strips look great in the pan but not good for your prostate

Eating pan-fried red meat may increase your risk of developing advanced prostate cancer. Men who ate 1.5 servings of pan-fried red meat a week were 30% more likely to develop advanced prostate cancer compared to men who did not eat fried red meat. If a man consumed more than 2.5 servings of pan-fried red meat a week, the risk of advanced prostate cancer rose to 40%.

The study was reported in the August issue of Carcinogensis.

Bottom Line: Pan-fried red meat may taste good but it just may be deleterious to your prostate gland. If you are going to eat pan-fried red meat, I suggest you do it only on an occasional basis.

New Hope For Prostate Cancer Patients

Prostate cancer is the most common non-skin cancer in the USA; 242,000 cases are expected this year. There is no way yet to distinguish between the benign ones that will stay in the prostate and the dangerous ones that will start creeping into the bones, the mostly likely place of spread.
Most doctors manage prostate cancer in the advanced stages by finding ways to decrease the testosterone level as it is felt that testosterone is responsible for the growth of prostate cancer. For decades, men who relapsed were treated with drugs or surgery that decreased the testosterone level. A common medication used in the late 1990s and early 2000 was Lupron or similar drugs. If men failed on Lupron or similar drugs, they were told to wait and get their affairs in order as death was imminent.

Then in the early ’90s, when troubled financier Michael Milken publicized his prostate cancer battle and the lack of funding. In 2005, the Department of Defense began to invest heavily, and drug companies got interested. Collaboration of activists, academics, government and drug makers led to more than 100 clinical trials.
Provenge bought him another 2 years with no cancer growth, long enough to qualify for a trial of enzalutamide last year. His prostate- specific antigen number, a measure of the disease’s progression , is down from 30 to 4.5, as good as it has been in decades.

Most trials are conducted on patients who have advanced disease. The drugs might be more effective if started earlier, but that’s yet to be proven.
Now, figuring out which patients will do well on which drugs is mostly a game of chance. “In the future, the hope is we’ll be smarter and be able to pick out the right therapies at the right time,”

So what are the drugs that have been shown to prolong life?
Provenge is a vaccine approved by the FDA that primes a man’s immune system to attack prostate cancer cells. A course consists of three treatments.

Cabazitaxel is FDA approved and consists of six cycles of treatment.

Abiraterone deprives tumors of testosterone.

Enzalutamide blocks the ability of testosterone to enhance cancer cells growth.

Radium 223 is awaiting FDA approval and carries radioactive particles deep into the bone where cancer from the prostate gland has spread and kills the cancer cells in the bone.

Bottom Line: Prostate cancer remains one of the most common cancers in men. New treatments are on the horizon and men need to speak with their doctors about the most effective treatments that can help prolong their lives.

Take Two (Aspirin) and You May Not Need To Call Me In the Morning-Aspirin May Decrease Death From Prostate Cancer

A recent article from the New York Times reports that men treated for prostate cancer who took aspirin regularly for other medical conditions were less likely to die of their cancer than patients who weren’t taking aspirin. Prostate cancer is the most common cancer occurring among men and the No. 2 cancer killer of men.

The new report adds to a growing body of evidence suggesting that aspirin may play a beneficial role in the treatment and possibly the prevention of a variety of cancers including prostate and colon cancer.
In the new study looked at nearly 6,000 men who had localized prostate cancer and were treated with surgery or radiotherapy. Just over one-third of the men, or 2,175 of the 5,955, were taking aspirin.
Those taking aspirin were less than half as likely as those who were not to die of prostate cancer over a 10-year period. The prostate cancer death rate for those taking aspirin was 3 percent, the researchers found, compared with 8 percent for those who did not. The aspirin users were also significantly less likely to experience a recurrence of prostate cancer or have the disease spread to the bones, the study found.

The study is not the first to find a reduction in recurrence among prostate cancer patients who took aspirin. Researchers at the Fox Chase Cancer Center in Philadelphia reported this year that among 2,051 prostate cancer patients, those not using aspirin were twice as likely to experience a recurrence within 18 months, as detected by rising scores on the prostate-specific antigen test, a strong predictor of metastasis and survival.

While many Americans, inclduing myself, use baby aspirin to reduce their risk of heart disease, taking aspirin regularly is risky. Patients generally are advised to do so only when their cardiac risk is presumed to outweigh the risks, which include an increase in gastrointestinal bleeding and hemorrhagic stroke.
Dr. Otis Brawley, chief medical officer of the American Cancer Society, said he believes that aspirin’s anti-inflammatory properties may play a role in the prevention of both heart disease and cancer.

Bottom Line: Aspirin may be helpful for preventing heart diease and preventing recurrence of prostate cancer. It’s inexpensive, readily available, and has very risks and complications. Check with your doctor before embarking on aspirin therapy. Remember, an aspirin a day may keep the prostate cancer away

Prevent Cancer Recurrence-Eat Right and Exercise a Lot

A recent study from Ccancer Journal for Clinicians (April 26, 2012) indicated that prostate cancer patients and those with other forms of cancer should maintain a healthy weight, exercise, and each a healthy diet in order to decrease the risk of recurrence.  Strong evidence shows that both healthy diet and exercise can prevent cancers from recurring.  So if you have cancer and our recovering from cancer surgery, radiation or chemotherapy you need to be plenty of fruits and vegetables, decrease your consumption of red meat, limit your carbohydrate intake, and exercise at least 20 minutes a day 4 days a week.

 

Tea, Pee, and Your Prostate Gland-What’s the Connection?

A recent report from University of Glasgow in the U.K. reported that black tea may be deleterious to your prostate and may even increase your risk of prostate cancer.
They studied approximately 6,000 men between the ages of 21-75 for the past four decades and discovered that those who consumed more than seven cups of black tea daily were twice as likely to develop prostate cancer than those who drank only three, or less cups.
This report is just a little confusing to both doctors and the public as previous research had shown that drinking tea was found to lower the risk of cancer as well as diabetes and heart disease. Yet despite the new findings the investigators believe that drinking black tea may still have an overall positive effect on health that trumps any connection to prostate cancer.

An explanation: Perhaps heavy tea drinkers were more likely not to be overweight, have good cholesterol levels, and avoid alcohol. As a result, it could just be possible that the heavy tea drinkers tend to live to older ages which is exactly the time in a man’s life when prostate cancer is more common.

So what is tea?
Tea is one of the most ancient and popular beverages consumed around the world. Black tea accounts for about 75 percent of the world’s tea consumption. In the United States, United Kingdom (UK), and Europe, black tea is the most common tea beverage consumed. Black tea is produced when tealeaves are wilted, bruised, rolled, and fully oxidized. Dry heat or steam can be used to stop the oxidation process, and then the leaves are dried to prepare them for sale. Tea is brewed from dried leaves and buds (either in tea bags or loose), prepared from dry instant tea mixes, or sold as ready-to-drink iced teas. So-called herbal teas are not really teas but infusions of boiled water with dried fruits, herbs, and/or flowers.

Black Tea

What’s so healthy about tea?
Tea is composed of polyphenols, alkaloids (caffeine, theophylline, and theobromine), amino acids, carbohydrates, proteins, chlorophyll, volatile organic compounds (chemicals that readily produce vapors and contribute to the odor of tea).
The polyphenols, a large group of plant chemicals that includes the catechins, are thought to be responsible for the health benefits that have traditionally been attributed to tea.
The highest polyphenol concentration is found in brewed hot tea, less in instant preparations, and lower amounts in iced and ready-to-drink teas.
Teas and Cancer

Among their many biological activities, the predominant polyphenols in black teas have antioxidant activity. These chemicals have substantial free radical scavenging activity and may protect cells from DNA damage caused by free radicals. Tea polyphenols have also been shown to inhibit tumor cell proliferation and induce apoptosis in laboratory and animal studies. In other laboratory and animal studies, tea catechins have been shown to inhibit angiogenesis and tumor cell invasiveness. In addition, tea polyphenols may protect against damage caused by ultraviolet (UV) B radiation, and they may modulate immune system function. Furthermore, teas have been shown to help protect against tumor development. Although many of the potential beneficial effects of tea have been attributed to the strong antioxidant activity of tea polyphenols, the precise mechanism by which tea might help prevent cancer has not been established.

Tea has long been regarded as an aid to good health, and many believe it can help reduce the
risk of cancer. Although tea and/or tea polyphenols have been found in animal studies to inhibit tumorigenesis at different organ sites, including the skin, lung, oral cavity, esophagus, stomach, small intestine, colon, liver, pancreas, and mammary gland, the results of human studies—both epidemiologic and clinical studies—have been inconclusive.


The results of these studies have often been inconsistent, but some have linked tea consumption to reduced risks of cancers of the colon, breast, ovary, prostate, and lung. The inconsistent results may be due to variables such as differences in tea preparation and consumption, the types of tea studied (green, black, or both), the methods of tea production, the bioavailability of tea compounds, genetic variation in how people respond to tea consumption, the concomitant use of tobacco and alcohol, and other lifestyle factors that may influence a person’s risk of developing cancer, such as physical activity or weight status.


Two other clinical trials, both uncontrolled studies, investigated the use of green tea extracts to reduce prostate-specific antigen levels in men with prostate cancer and found no evidence of such a reduction.


What does the National Cancer Institute (NCI) have to say about tea? NCI is a research institution. It develops evidence-based research results for others to interpret. In general, therefore, NCI does not make recommendations about specific medical or dietary interventions.
 Moreover, as noted above, the evidence regarding the potential benefits of tea consumption in relation to cancer is inconclusive at present.

So what is my Bottom Line advice? Black tea may be beneficial to other organs and systems but the jury is out on the prostate gland. Therefore, heavy tea drinkers need to see their doctor once a year and have a PSA blood test and a digital rectal exam.

Vitamin D May Reduce Your Risk Of Prostate Cancer

A new study suggests that vitamin D may protect against prostate cancer. Men around age 65 who had a positive biopsy for prostate cancer who took 4000 IU/day of Vitamin D for a full year had a 55% decrease in the number of follow up positive prostate biopsies. Men who did not take vitamin D, 2\3 had progression compared to only 1\3 who took vitamin D.

Bottom Line; This is a report of a small study and certainly the results are encouraging but preliminary and more testing needs to be done. But as my wise Jewish mother would say, “It may not help, but it voidn’t hoit!”