Watching The Results On Watchful Waiting For Prostate Cancer

I have seen many changes in medicine during my 35 year career but nothing has changed more dramatically than the diagnosis and treatment of prostate cancer. When I was a medical student in 1968, the treatment was primarily removing a man’s testicles or castration. This drastic treatment removed the source of testosterone, which was the “fuel” to cause prostate cancer to grow. Then came surgery and radiation therapy followed by chemotherapy and now high energy focused ultrasound or HIFU. But many of these treatments have significant side effects like impotence and urinary incontinence which significantly impact a man’s quality of life. As a result conservative forms of treatment have been sought after that doen’t have the side effects and yet prolongs a man’s life. One of those options is watchful waiting or active surveillance where the diagnosis is made and no treatment is used and the man returns regularly for a physical examination which incldues a digital rectal exam, a PSA test and perhaps a repeat prostate ultrasound examination.

Because prostate cancer often grows very slowly, some men (especially those who are older or have other serious health problems) may never need treatment for their prostate cancer. Instead, your doctor may recommend approaches known as expectant management, watchful waiting, or active surveillance.

Active surveillance or watchful waiting is often used to mean monitoring the cancer closely with prostate-specific antigen (PSA) blood tests, digital rectal exams (DREs), and ultrasounds at regular intervals to see if the cancer is growing. Prostate biopsies may be done as well to see if the cancer is becoming more aggressive. If there is a change in your test results, your doctor would then talk to you about treatment options.
With active surveillance, your cancer will be carefully monitored. Usually this approach includes a doctor visit with a PSA blood test and DRE about every 3 to 6 months. Transrectal ultrasound-guided prostate biopsies may be done every year as well.
Treatment can be started if the cancer seems to be growing or getting worse, based on a rising PSA level or a change in the DRE, ultrasound findings, or biopsy results. On biopsies, an increase in the Gleason score or extent of tumor (based on the number of biopsy samples containing tumor) are both signals to start treatment (usually surgery or radiation therapy).

Active surveillance allows the patient to be observed for a time, only treating those men whose cancer grows, and so have a serious form of the cancer. This lets men with a less serious cancer avoid the side effects of a treatment that might not have helped them live longer.

An approach such as this may be recommended if your cancer is not causing any symptoms, is expected to grow slowly (based on a low Gleason score, i.e., 6), and is small and contained within the prostate. This type of approach is not likely to be a good option if you have a fast-growing cancer (for example, a high Gleason score, >8) or if the cancer is likely to have spread outside the prostate (based on PSA levels). Men who are young and healthy are less likely to be offered active surveillance, out of concern that the cancer will become a problem over the next 20 or 30 years.
Watchful waiting is also an option for older men who have other co-morbid conditions such as heart disease, diabetes, or another cancer that has been previously treated. A rule of thumb is that if a man has a life expectancy of less than 10 years and has a low grade prostate cancer, then watchful waiting would certainly be suggestion.

Active surveillance is a reasonable option for some men with slow-growing cancers because it is not known whether treating the cancer with surgery or radiation will actually help them live longer. These treatments have definite risks and side effects that may outweigh the possible benefits for some men.
So far there are no randomized studies comparing active surveillance to treatments such as surgery or radiation therapy. Some early studies of active surveillance (in men who are good candidates) have shown that only about a quarter of the men need to go on to definitive treatment with radiation or surgery.

Bottom Line: Prostate cancer is usually a slow growing tumor that affects millions of American men. One consideration for an older man, with a low Gleason score, and no symptoms from the prostate cancer would be watchful waiting. Each man with prostate cancer needs to have a discussion with his doctor to decide which treatment is best in his situation.

Lose Weight and It May Affect Your Risk of Prostate Cancer

Prostate cancer is a slow growing tumor that affects millions of American men. More than 2 million men in the U.S. are prostate cancer survivors. There are 250,000 new cases of prostate cancer discovered each year. Although more than 80% of prostate cancer patients are diagnosed with cancer confined to the prostate gland, the relative 10-year survival rate is 93% for all men regardless of how far advanced is the cancer. Most men are interested in finding out what they can do to prevent prostate cancer. This blog will discuss how exercise may help prevent prostate cancer.

There is new evidence that obesity increases the risk of prostate cancer and, more importantly, regular exercise decreases the risk of prostate cancer. 
Studies of exercise and prostate cancer risk have mostly shown that men who exercise may have a reduced risk of prostate cancer. Exercise has many other health benefits and may reduce your risk of heart disease and other cancers. Exercise can help you maintain your weight, or it can help you lose weight.

A study performed by researchers at the Harvard School of Public Health examined the records of 2,705 men who had been diagnosed with nonmetastatic prostate cancer over 18-years. The men in the study reported the time they spent exercising on a weekly basis. This included running, bicycling, walking, swimming, other sports, and even outdoor work. Men who reported vigorous activity for at least three hours per week had a 61% lower risk of a prostate cancer-specific death, compared with men who exercised for less than an hour per week.

The results of this study suggests that men can reduce their risk of prostate cancer progression after a diagnosis of prostate cancer by adding physical activity to their daily routine.
A little is better than none

The researchers observed benefits at very attainable levels of activity and that the study suggests that men with prostate cancer should do some physical activity for their overall health, even if it is a small amount, such as 15 minutes of activity per day of walking, jogging, biking, or mowing the law\gardening.

There is good evidence that doing vigorous activity for three or more hours per week may be especially beneficial for prostate cancer, as well as overall health. The research shows a significant risk reduction for prostate cancer mortality with increasing vigorous activity.
The study is published online in the Journal of Clinical Oncology.

Decreased physical activity, which may be the result of the cancer itself or the treatment, can lead to tiredness and lack of energy. Regular, moderate exercise can decrease these feelings, help you stay active, and increase your energy. Even during cancer therapy, it is often possible to continue exercising.

If you don’t already exercise, make an appointment with your doctor to see if it’s OK for you to get started. When you begin exercising, go slowly. Add physical activity to your day by parking your car farther away from where you’re going, and try taking the stairs instead of the elevator. Aim for 30 minutes of exercise most days of the week.

Risk of prostate cancer is higher in men who are African American descent or who have a father, brother, uncle, or close relative with prostate cancer. Talk to your doctor about your risk. 
Some men have an increased risk of prostate cancer. For those with a very high risk of prostate cancer, there may be other options for risk reduction, such as medications.

Bottom Line: Prostate cancer is a common malignancy that affects millions of American men. There are risks of increasing prostate cancer and steps you can take like improving your diet and increasing your exercise level that will decrease the risk of prostate cancer.

Eat Your Way To Prostate Health-Prostate Cancer Risk Reduction Through Diet

Prostate cancer is the most common cancer in men and the second most common cause of death from cancer in men. (Lung cancer causes more deaths than prostate cancer) Whereas the cause of lung cancer can be clearly traced to smoking, the causes of prostate cancer are less well known. However, there are dietary recommendations that may make a difference.
According to a study by the Mayo Clinic, choosing a healthy diet may be beneficial. 
There is some evidence that choosing a healthy diet that’s low in fat and full of fruits and vegetables may reduce your risk of prostate cancer, though study results haven’t always agreed. If you want to reduce your risk of prostate cancer, consider trying to:
Choose a low-fat diet. Foods that contain fats include meats, nuts, oils and dairy products, such as milk and cheese. In studies, men who ate the highest amount of fat each day had an increased risk of prostate cancer. While this association doesn’t prove that excess fat causes prostate cancer, reducing the amount of fat you eat each day has other proven benefits, such as helping you control your weight and helping your heart. To reduce the amount of fat you eat each day, limit fatty foods or choose low-fat varieties. For instance, reduce the amount of fat you add to foods when cooking, select leaner cuts of meat and choose low-fat or reduced-fat dairy products.
Eat more fat from plants than from animals. In studies that looked at fat and prostate cancer risk, fats from animals were most likely to be associated with an increased risk of prostate cancer. Animal products that contain fats include meat, lard and butter. When possible, use plant-based fats in place of animal fats. For instance, cook with olive oil rather than butter. Sprinkle nuts or seeds on your salad rather than cheese.
Increase the amount of fruits and vegetables you eat each day. Fruits and vegetables are full of vitamins and nutrients that are thought to reduce the risk of prostate cancer, though research hasn’t proved that any particular nutrient is guaranteed to reduce your risk. Eating more fruits and vegetables also tends to make you have less room for other foods, such as high-fat foods. Increase the amount of fruits and vegetables you eat each day by adding an additional serving of a fruit or vegetable to each meal. Eat fruits and vegetables for snacks.
Eat fish. Fatty fish — such as salmon, sardines, tuna and trout — contain a fatty acid called omega-3 that has been linked to a reduced risk of prostate cancer. If you don’t currently eat fish, try adding it to your diet.
Reduce the amount of dairy products you eat each day. In studies, men who ate the most dairy products — such as milk, cheese and yogurt — each day had the highest risk of prostate cancer. But study results have been mixed, and the risk associated with dairy products is thought to be small.
Drink green tea. Studies of men who drink green tea or take green tea extract as a supplement have found a reduced risk of prostate cancer. If you like to drink tea, consider choosing green tea.
Try adding soy to your diet. Diets that include tofu — a product made from soy beans — have been linked to a reduced risk of prostate cancer. It’s thought that the benefit of soy comes from a specific nutrient called isoflavones. Other sources of isoflavones include kidney beans, chickpeas, lentils and peanuts.
Drink alcohol in moderation, if at all. If you choose to drink alcohol, limit yourself to no more than a drink or two each day. There’s no clear evidence that drinking alcohol can affect your risk of prostate cancer, but one study found men who drank several drinks each day over many years had an increased risk.
Maintain a healthy weight 
Men with a body mass index (BMI) of 30 or higher are considered obese. Being obese increases your risk of prostate cancer. If you are overweight or obese, work to lose weight. You can do this by reducing the number of calories you eat each day and increasing the amount of exercise you do.
Bottom Line: If you are concerned about the risk of prostate cancer or if you have a family relative such as a father, brother, cousin or uncle with prostate cancer which will certainly increase your risk of prostate cancer, you may want to consider a dietary modification as I have described which may decrease your risk of developing prostate cancer.

Protect The Nuts-Testicular Injuries

This title came from a program called Save The Nuts, www.protectthenuts.com, which is focused on men checking themselves for testicular cancer.  A man’s testicles are important for reasons, which include their concept of their manhood, their confidence, fertility, and potency.  Despite the vulnerable position of the testicles, testicular trauma is relatively uncommon. Mobility of the scrotum may be one reason severe injury is rare. The testicles are also prone to injury because they are not protected by muscle or bone. Given the importance of preserving fertility, traumatic injuries of the testicle deserve careful attention.  This blog will discuss the common conditions associated with trauma to those gems down there!             

The anatomy of testicles

Testicles are also known as testes (one is a testis) or ‘balls’. They are two small, oval-shaped male sex glands that produce sex hormones and sperm. Each testicle is housed in a fibrous outer covering called the tunica albuginea. Sperm production needs a temperature that is around 2 °C lower than the body, which is why the testicles are located outside the body in a sack of skin (the scrotum).

Testicular torsion

The spermatic cord attaches the testicle to the body. Testicular torsion occurs when the spermatic cord twists and cuts off the blood supply to the testicle. This condition can occur at any age, but tends to be more common between the onset of puberty and the mid-20s. It requires urgent medical attention.

Hard physical activity can cause this twisting of the cord. In most cases, however, it is caused by abnormalities in a male’s anatomy (body structure and organs) that make it easier for the testicle to twist or rotate around the cord.

Symptoms of testicular torsion include:

• Severe pain
• Scrotal swelling
• Nausea and vomiting.

These symptoms can often be confused with an infection of the testicles. An infection should not be diagnosed until torsion has been ruled out.

Urgent medical attention is needed to save the testicle when torsion is diagnosed. Surgery must untwist the spermatic cord and restore blood flow to the testicle. A doctor uses physical examination and ultrasound scans to make the diagnosis. Sometimes, a doctor can only make a conclusive diagnosis at the time of surgical exploration.

The survival rate of the affected testicle is poor unless surgery is performed within four to six hours. Unnecessary investigations should not take place if torsion is suspected, as delays to surgery can affect the viability of the testis. If the blood supply has been disrupted for too long, the testis may not be viable or salvageable and may need to be removed.

In many cases, the surgeon will also secure the spermatic cord on the unaffected side, to prevent future torsion of the other testicle. If the torted testicle has to be removed, then a surgeon can put a prosthesis or silicone testis into the scrotum for cosmetic reasons.

Other conditions that can affect the testicles include:

• Epididymitis – the epididymis is a collection of small tubes located at the back of each testicle. They collect and store sperm. Epididymitis is infection and inflammation of these tubes. Causes include urinary tract infections and sexually transmissible infections (STIs). Treatment includes antibiotics
• Epididymo-orchitis – infection of the epididymis and testicle that causes inflammation and pain. Treatment includes antibiotics
• Varicoceleor varicose veins – 10 to 15 per cent of men have a varicocele, where veins draw blood from the testicle. This blood has to rise against gravity when the man stands up. Valves in the veins help this process. If the valves don’t work, blood pools in the veins. This swells the veins and gives the appearance of ‘varicose veins’. Varicoceles usually don’t need treatment, unless the varicocele is severe enough to cause discomfort or impair fertility. The links between varicocele and infertility are complex and research is ongoing. Treatment includes surgery or radiological techniques that can block the testicular veins
• Haematocele – a blood clot caused by trauma or injury to the testicles or scrotum. In some cases, the body is able to reabsorb the blood. If not, the person will need surgery to remove the clot
• Hydrocele – abnormal build-up of fluid that causes the affected testicle to swell. In some cases, the body can reabsorb the fluid. Even though the condition is painless, the hydrocele may become so large that the person will need surgery to remove it
• Spermatocele – an abnormal build-up of sperm-filled fluid next to the epididymis, which feels like a separate lump on the testicle. This is harmless, but can be removed surgically if it becomes large or bothersome. It is more common after a vasectomy
• Undescended testicles – either one or both testicles are missing from the scrotum and are lodged inside the lower abdomen. Premature and low-weight newborn boys are most prone to undescended testicles. This condition is a known risk factor for testicular cancer and strongly related to infertility. Unless the testicle is brought down into the scrotum by 12 months of age, there is a high risk of damage to sperm production in later life
• Testicular cancer – an abnormal growth or tumour that appears as a hard and usually painless lump in either testicle. In most cases, testicular cancer can be cured if the person seeks medical treatment early. Surgical removal of the affected testicle (orchidectomy) is usually the first treatment for all testicular cancer.

Suggestions on how to reduce the risk of testicular problems include:

• Take all reasonable precautions to prevent accidents. For example, drive safely and always wear a seatbelt.
• Protect yourself from sexually transmissible infections (STIs) by wearing a condom.
• Always use protective equipment such as a jockstrap or hard cup while playing sports.
• If you injure your testicles, always seek urgent medical advice.
• Perform testicular self-examination (TSE) once every month. Regular TSE helps you become familiar with the look, feel and shape of your testicles so you will notice any abnormalities. See your doctor for further information on how to perform TSE.

Always see your doctor if you experience any scrotal or testicular pain or unusual symptoms, or if you find a lump or swelling.

 Bottom Line

Those gems between our legs are worthy of protecting.  If you feel any discomfort or lumps or bumps down there, see your doctor your potency and fertility are worth protecting.

 

When The Foreskin Doesn’t Retract-Phimosis

On occasion there are men who are not circumcised and unable to retract their foreskins.  This condition is referred to as phimosis.  The condition usually results when the man fails to retract his foreskin and a few drops of urine collects under the foreskin and sets ups an infection resulting in scarring and tightening of the foreskin making retraction difficult and sometimes impossible. 

Phimosis may be detected in males who report painful erections, blood in the urine, recurrent urinary tract infections, or a weakened urinary stream.

Patients with phimosis may require an emergency intervention and should be referred to a urologist prior to development of irreversible penile damage. 

If the foreskin cannot be retracted and hygiene will be a continued problem., then a surgical procedure needs to be performed.  This is a last resort, to be performed by a urologist, to achieve the necessary reduction in infections and allow the man to have optimal penile hygiene.

Surgical methods range from the complete removal of the foreskin to more minor operations to relieve foreskin tightness:

•                Circumcision is sometimes performed for pathological phimosis, and is effective.

•                Dorsal slit is a single incision along the upper length of the foreskin without removing any tissue.

•                Preputioplasty, is a limited dorsal slit with a relaxing incision is made on the constricting scar tissue of the foreskin can be an effective alternative to circumcision.  It has the advantage of only limited pain and a short time of healing relative to circumcision, and avoids cosmetic effects.

Bottom Line: A tight foreskin is a condition that requires medical attention and the man should be referred to a urologist  for further treatment. 

The End Of Screening For Prostate Cancer In Men Over Age 75

In a move that could lead to significant changes in medical care for older men, a national task force on Monday recommended that doctors stop screening men ages 75 and older for prostate cancer because the search for the disease in this group was causing more harm than good.

The guidelines, issued by the U.S. Preventive Services Task Force and published on Tuesday in the Annals of Internal Medicine, represent an abrupt policy change by an influential panel that had withheld any advice regarding screening for prostate cancer, citing a lack of reliable evidence.
Screening is typically performed with a blood test measuring prostate-specific antigen, or PSA, levels. Widespread PSA testing has led to high rates of detection. Last year, more than 218,000 men learned they had the disease.
Yet various studies suggest the disease is “overdiagnosed” — that is, detected at a point when the disease most likely would not affect life expectancy — in 29 percent to 44 percent of cases. Prostate cancer often progresses very slowly, and a large number of these cancers discovered through screening will probably never cause symptoms during the patient’s lifetime, particularly for men in their 70s and 80s. At the same time, aggressive treatment of prostate cancer can greatly reduce a patient’s quality of life, resulting in complications like impotency and incontinence.
Past task force guidelines noted there was no benefit to prostate cancer screening in men with less than 10 years left to live. Since it can be difficult to assess life expectancy, it was an informal recommendation that had limited impact on screening practices. The new guidelines take a more definitive stand, however, stating that the age of 75 is clearly the point at which screening is no longer appropriate.
Dr. Calonge said it was important that the guidelines not be viewed as “giving up” on older men. While the new rules should discourage routine testing of older patients, the recommendations will not prevent a man from seeking screening if he desires it, Dr. Calonge said. The new guidelines are not expected to alter Medicare’s current reimbursement for annual PSA screening of older men.
The guidelines focus on the screening of healthy older men without symptoms and will not affect treatment of men who go to the doctor with symptoms of prostate cancer, like frequent or painful urination or blood in the urine or the semen.
While the verdict is still out on younger men, the data for older men are more conclusive, experts say. The American Cancer Society and the American Urological Association both say annual PSA screening should be offered to average-risk men 50 and older, but only if they have a greater than 10-year life expectancy.
Treatments for prostate cancer can cause significant harm, rendering men incontinent or impotent, or leaving them with other urethral, bowel or bladder problems. Hormone treatments can cause weight gain, hot flashes, loss of muscle tone and osteoporosis.
Bottom Line: If you are 75 years of age or older, you probably don’t need any additional screening for prostate cancer.

This blog was excerpted from The New York Times, October 4, 2013

Sex After a Heart Attack

A man has a recent heart attack. He is eager to get back in the saddle and remembers the movie, Something’s Gotta Give, when Jack Nicholson, who had a recent heart attack, asks his doctor about when “his best friend” can start getting back into action. He’s told that he has to wait until he can climb two flights of stairs without shortness of breadth or chest pain. Both the man and his partner are concerned if sex trigger could another heart attack.
It is well documented that fewer than 1% of heart attacks come from having sex. It makes sense to think of sex as a form of exercise: If your doctor clears you for physical activity, you’re also likely safe for sex. Remember the two flights of stairs test.
Most men and their partners are uncomfortable broaching the topic with their doctor. Most doctors are comfortable talking about sexual intimacy and you shouldn’t avoid the topic. Often the patient is surprised — or even relieved — that the doctor raises the subject.
Similar to any type of exercise, if you begin to feel symptoms such as chest pain, abnormal shortness of breath, fatigue, dizziness, or palpitations, it definitely makes sense to slow down what you’re doing, whether you’re a man or a woman. If you’re pretty certain it’s angina, which is temporary pain or pressure in the chest when the heart doesn’t get enough oxygen, it might help to take your nitroglycerin.
The exception to that advice is for men who use medication for erectile dysfunction such as Viagra, Levitra, and Cialis — it’s dangerous to take nitroglycerin. Your blood pressure can fall to dangerously low levels, and there’s an increased risk of heart attack and even death. If you’re on an erectile dysfunction drug and have heart-related symptoms during sex, call your doctor.
Bottom Line: Sexual intimacy is important to men at all ages and includes men who have had a recent heart attack. A candid conversation will help you get back to enjoying a sexual relationship with your significant other. Talk to your doctor

Smoking and Bladder Cancer-Now Another Reason To Stop Smoking

Just Say “No”

Some important facts about bladder cancer include:
• Bladder cancer is the sixth most commonly diagnosed cancer in the U.S.
• More than 72,000 new cases of bladder cancer are expected to be diagnosed in 2013.
• Approximately 15,000 people will die from the disease this year alone.
• Bladder cancer is three times more common in men than in women.
• One in 42 people will be diagnosed with bladder cancer during their lifetime.

Cigarette smokers have a higher risk of bladder cancer than non-smokers. Smoking tobacco is the most important known risk factor for bladder cancer. Smoking has been shown to be responsible for half of female bladder cancer cases. The increase in the proportion of smoking-attributable bladder cancer cases among women is likely explained by the greater prevalence of smoking among women.
Here’s the good news: As with many other smoking-related cancers, smoking cessation was associated with reduced bladder cancer risk.
Bottom Line: Smoking is certainly implicated as a cause of bladder cancer. By stopping the use of cigarettes, you can decrease the risk of bladder cancer.