Archive for the ‘PSA’ Category

Elevated PSA Linked to Shiftwork

February 16, 2015

Men who work night shifts or rotating shifts are more likely to have elevated PSA levels than men who do not.
In an analysis of data from the National Health and Nutrition Examination Survey (2005-2010), Erin E. Flynn-Evans, PhD, of Brigham and Women’s Hospital in Boston, and colleagues found shiftworkers had a 2.6 times increased risk of an elevated PSA (4.0 ng/mL or higher) compared with non-shiftworkers after adjusting for confounders.
The researchers, who published their findings online ahead of print in the Journal of the National Cancer Institute, concluded that sleep or circadian disruption is associated with elevated PSA, indicating that shiftworking men likely have an increased risk of developing prostate cancer.
A previous prospective cohort study of Japanese rotating-shift workers demonstrated that, compared with day workers, rotating-shift workers had a significant threefold increased risk of prostate cancer after adjusting for age, family history of prostate cancer, and other potential confounders, according to a report in the American Journal of Epidemiology (2006;164;549-555).

Take Home Message: If you are caring for a middle age man who does shift work, it is a good idea to encourage him to get a PSA and a digital rectal exam annually.

More FAQs From My Patients

February 16, 2015

I have a high cholesterol level. Is there anything I can do to lower the cholesterol level besides medications, i.e., statins?
Yes, there are cholesterol lowering foods that are effective and have absolutely no side effects. These include:
Soluble fiber of 25gms each day is helpful and good for the colon as well. Good sources of soluble fiber include legumes such as peas and beans; cereal grains such as oats and barley and vegetables and fruits such as carrots, apples, and dried plums (prunes).
Nuts to the rescue. Although nuts are high in fat, the fats are predominantly monounsaturated and polyunsaturated, which are known to decrease LDL cholesterol levels or bad cholesterol. By eating a daily helping of nuts — about 2.4 ounces — results in an average 5% reduction in total cholesterol concentration. Nuts that will help lower LDL cholesterol levels include almonds, walnuts, peanuts, pecans, macadamias and pistachios.
Plant sterols and stanols, plant compounds that are structurally similar to cholesterol, partially block the absorption of cholesterol from the small intestine. They lower levels of LDL cholesterol without adversely affecting high-density lipoprotein (HDL or “good”) cholesterol levels. Plant sterols and stanols, plant compounds that are structurally similar to cholesterol, partially block the absorption of cholesterol from the small intestine. They lower levels of LDL cholesterol without adversely affecting high-density lipoprotein (HDL or “good”) cholesterol levels.
So you can begin by decreasing your consumption of red meat, butter, and high cholesterol containing seafood such as crayfish (heaven forbid!) shrimp and lobster and try these other non-medical options. If these do not work, then talk to your doctor about medication.

I am thinking of having a vasectomy. Is there any risk of erectile dysfunction or impotence?
No, you have nothing to worry about. A vasectomy ONLY prevents the sperm from entering into the ejaculate or seminal fluid. It does not affect the testosterone level or the ability to engage in sexual intimacy. If your erections are good before the vasectomy, they will remain just like they were prior to the vasectomy. So it is safe to proceed with the “prime cut”!

I am a man 78 years of age. Do I need to have a PSA test for prostate cancer?
No, the American Cancer Society and the American Urological Association do not recommend screening for prostate cancer with the PSA test in men more than 75 years. Cancer screening tests — including the prostate-specific antigen (PSA) test to look for signs of prostate cancer — can be a good idea in younger men between 50-75 but not in men over age 75. A normal PSA test, combined with a digital rectal exam, can help reassure you that it’s unlikely you have prostate cancer. But getting a PSA test for prostate cancer is not be necessary for men 75 and older.

I am 40 years of age and ate some red beets. My urine turned red. Is that normal after consuming red beets?
Usually red urine after red beet consumption is a result of a pigment, betalain, in the red beets and is nothing to worry about. However, if the red persists more than 24 hours after consuming the beets, then it is important to see your physician and have a urine examination. When the red color persists, this is referred to as hematuria. Hematuria is a clinical term referring to the presence of blood, specifically red blood cells, in the urine. Whether this blood is visible only under a microscope or present in quantities sufficient to be seen with the naked eye, hematuria is a sign that something is causing abnormal bleeding in the patient’s genitourinary tract. For more information on hematuria, please go to my website: http://neilbaum.com/articles/hematuria-blood-in-the-urine

Movember-A reminder To Have a Prostate Check With Your Doctor

November 4, 2014

November is a month dedicated to men’s health and male health awareness.  Thousands of men will change their appearance this month by growing a moustache for the 30 days of Movember.

Not only are the ‘Mo bros’ bring back the moustache, they are raising funds and awareness for prostate cancer, testicular cancer and mental health.

By taking a few simple steps such as maintaining a good diet and taking action early when experiencing a health issue, every man can improve their chances of living a happy and healthy life.

If prostate cancer is spotted early, prostate cancer can be very effectively treated. And many men will be able to lead a normal life for years to come. Prostate cancer has one of the best survival rates of all cancers.

The most important thing to remember about prostate cancer is that even if the doctors confirm you have it, it doesn’t mean you will die of it,

Many of the men immediately start thinking about their own mortality and worrying about their families and loved ones after they are gone.

This is why ‘Movember’ is so important – to encourage men to be more proactive about looking after their own health.”

Prostate cancer is the most common cancer in men with 250,000 new cases each year and nearly 30,000 deaths in the U.S. It is often slow-growing, but there are more aggressive forms which need active treatment.

The prostate is a walnut-sized gland located between the bladder and the penis which secretes fluid that nourishes and protects sperm.

Conditions that can affect the prostate include infections, enlarged prostate – the gland grows in nearly all men over 50, prostate infections, and prostate cancer.

The first step is to make an appointment with your primary care physician and request a PSA test. If you have an elevated PSA level, your doctor will often refer you to a urologist.  The urologist may recommend a prostate biopsy and will treat you as an individual and work out what the best treatment is depending on your age, health and other conditions you may have.

Surgery or radiotherapy is not right for everyone and sometimes a ‘watch and wait’ or surveillance plan of action is recommended if the prostate cancer is not aggressive.

A lot of men find it embarrassing to turn to a doctor about men’s issues about urinary symptoms as they fear they have prostate cancer.

A much more common condition is the enlarged prostate gland.  This is a benign condition that impacts nearly all men over the age of 60 and causes difficulty with urination such as a decrease in the force and caliber of the urinary stream, urinary frequency, urgency of urination, and getting up at night to urinate.

The condition makes life uncomfortable as it can place pressure on the bladder and urethra, the tube through which urine passes, and can make it difficult to urinate or cause a frequent need to.

Most men can be helped with oral medication such as alpha blockers and medications to actually reduce the size of the prostate gland such as Proscar or Avodart.  If medications are in effective, there are minimally invasive procedures such as microwaves, lasers and now the new Urolift procedure.  This procedure has FDA approval and consists of using an implant that pulls the prostate gland open the us making urination much easier and more comfortable.

Prostate cancer – what you need to know if you are a man:

  • Ask your primary care Dr. for a special test (called PSA) – spotting prostate cancer early is really important , this is especially important if you are in your 50s or have any risk factors
  • Many diagnoses of prostate cancer will not cause problems and can be effectively treated and cured
  • There are no symptoms of prostate cancer unless it is very advanced
  • Contrary to popular belief difficulty in passing water is not a necessarily a sign of prostate cancer
  • You are three or four times more likely to develop the disease if your brother, father or close male relative has been diagnosed with it
  • If you are African American, then there is an increased risk you will develop prostate cancer.
  • It is a known fact that all men will develop prostate cancer if they live long enough.

Prostate and prostate cancer facts:

  • The prostate is a walnut-sized gland located between the bladder and the penis. It secretes fluid that nourishes and protects sperm
  • Conditions that can affect the prostate include infections, enlarged prostate (the gland grows in nearly all men over 50) and prostate cancer.
  • Prostate cancer is the most common cancer in men with 250,000 new cases each year and 30,000 deaths in the U.S.
  • Prostate cancer is often slow-growing, but there are more aggressive forms need active treatment
  • Most men who are diagnosed with prostate cancer survive 10 years or more
  • Familial inheritance represents 1-5% of all prostate cancers diagnosed
  • It is predicted that there will be 60% more diagnoses over the next 20 years
  • The number of advanced cancers is falling as awareness spreads

Prostate cancer – what happens:

The doctor will take some blood and test it to measure the amount of protein called prostate specific antigen – PSA.

It is normal to have a small amount of PSA in your blood. An elevated PSA level may be a sign of prostate cancer but equally the elevated PSA could be something like a urine\prostate infection or an enlarged prostate which is a benign condition.

An elevated PSA level may require an ultrasound prostate biopsy, which is where a small part of the prostate removed for further testing, or recommend an MRI scan, or both

If the scans and the biopsy confirm prostate cancer, your urologist will examine the information to determine exactly what risk type of cancer it is

You may need to have further scans such as bone scan or a CT scan

Types of treatment include active surveillance, radiotherapy or surgery depending on the type and severity of the cancer.

The important thing to remember is that prostate cancer can be effectively treated and you can live a perfectly normal life

More information on treatment options are available on my website: http://neilbaum.com/services/prostate-cancer

Bottom Line: Prostate cancer is the most common cancer in men and the second most common cause of death in American men. Most men with prostate cancer can be successfully treated. It starts with a digital rectal exam and a blood test, PSA.

Testosterone and the Prostate Gland-It’s Not Gasoline On a Fire

November 3, 2014

For the past two years I have made the decision of treating prostate cancer patients who are documented to be hypogonadal with testosterone replacement therapy. Many of my colleagues have asked me about this decision and I would like to provide you with the evidence that this treatment of hypogonadal men who have been treated for localized prostate cancer with either radical prostatectomy or radiation therapy is safe.

In the late 1980s Dr. Abraham Morgentaler, a urologist in Boston, Massachusetts, began researching the relationship between testosterone and prostate cancer.  Since the early 1940s testosterone had been believed to be a key contributor to the development of prostate cancer, and once cancer was established, testosterone was believed to be its fuel.  As a result, generations of medical students around the world were taught that providing additional testosterone to a man with prostate cancer was “like pouring gasoline on a fire.” On the flip side, it was similarly believed that low levels of testosterone protected a man from ever having prostate cancer.

As one of the first physicians in the modern era to offer testosterone therapy to otherwise healthy men with sexual problems, Dr. Morgentaler was concerned that this treatment, while effective, might precipitate rapid growth of undetected, “occult” prostate cancers in his patients.  In order to avoid causing more harm than good, Dr. Morgentaler took the bold step of performing prostate biopsies in these men to exclude the possibility that these men harbored an undetected prostate cancer, even though they had none of the standard indications for a biopsy, such as elevated PSA or a nodule.  Although it had been assumed these men were at extremely low risk for prostate cancer because of their low testosterone levels, Dr. Morgentaler and his colleagues found exactly the opposite. One in seven of these “normal” men that underwent biopsy was found to have cancer, a rate similar to that seen in men known to be at increased risk.

Dr. Morgentaler presented his findings at the annual meeting of the American Urological Association in 1995.  At the end of the presentation an influential chairman of a major urology department came to the microphone and loudly described this work as “garbage.” “Everyone knows high testosterone causes prostate cancer and low testosterone is protective,” he proclaimed in a booming voice.  The research was published the following year in the prestigious Journal of the American Medical Association.

As the testosterone and prostate cancer link became less persuasive, Dr. Morgentaler began to offer testosterone to men with pre-cancerous abnormalities on prostate biopsy, and reported no increased rate of subsequent cancer. Yet at his own hospital, the Beth Israel Deaconess Medical Center, a senior endocrinologist complained to the administration that this research was “dangerous”.

However, Dr. Morgentaler prevailed and went on to publish clinical research on the safety of testosterone in men with actual prostate cancer, some treated with radiation or surgery, and even in selected men with untreated prostate cancer.

Dr. Morgentaler’s results were difficult to accept initially because a longstanding treatment for advanced prostate cancer has been androgen deprivation, a surgical or medical treatment designed to permanently reduce testosterone levels as much as possible. Numerous studies in these men had shown improvement in prostate cancer with this treatment, so it seemed logical that raising testosterone would cause prostate cancer progression.

Dr. Morgentaler’s elegant solution to this apparent paradox was the saturation model, based on studies in humans, animals, and in prostate cancer cell lines in the laboratory. It turned out that prostate tissue does indeed require testosterone for optimal growth, but that it can only use a limited amount of testosterone (or its metabolite, dihydrotestosterone) before it reaches a maximum. In biological terms, this is called saturation.  Once saturation is achieved, additional testosterone has little or no capability to stimulate further growth. And saturation occurs at very low levels of testosterone, approximately 20ng\dl. This explained why testosterone treatments did not appear to harm men with existing or treated prostate cancer, namely because the cancers already had seen all the testosterone they could use.

The Evidence

A number of physicians have treated patients with testosterone despite the fact that they’d been treated for prostate cancer in the past. The first to publish their experience with doing this were Drs. Joel Kaufman and James Graydon, whose article appeared in the Journal of Urology in 2004.

In this article, Drs. Kaufman and Graydon described their experience in treating seven men with T therapy some time after these men had undergone radical prostatectomy as treatment for prostate cancer, with the longest follow-up being 12 years. None of the men had developed a recurrence of his cancer. Soon afterward, there was another paper by a group from Case Western Reserve University School of Medicine describing a similar experience in 10 men with an average follow-up of approximately 19 months. Then another group from Baylor College of Medicine reported the same results in 21 men.

In all these reports, not a single man out of the 38 treated with testosterone developed a cancer recurrence. It is important to emphasize that all these reports included only men who were considered good candidates because they were at low risk of recurrence anyway. And in some cases, the duration of time the men received T therapy was relatively short. But it was reassuring that none of the 38 men who had suffered from prostate cancer in the past and who were treated for years with testosterone had developed a recurrence of prostate cancer.

This reassuring experience was bolstered by the published experience of Dr. Michael Sarosdy, who reported the results of T therapy in a group of 31 men who had received prostate cancer treatment in the form of radioactive seeds, called brachytherapy. This less-invasive form of treatment does not remove the prostate, so theoretically there is the possibility that a spot of residual cancer might still be present. With an average of five years of follow-up in these men, none of the 31 men had evidence of cancer recurrence.

My Approach

Men who have low-grade prostate cancer, i.e., Gleason score of <6, and low stage disease, T1 or T2, and have a nadir of their PSA following curative treatment with either surgery or radiation for 9-12 months, and have symptoms of hypogonadism and documented low testosterone levels, are candidates for hormone replacement therapy. I provide them with educational materials similar to what is in this newsletter and request that they return every month to monitor their PSA levels. Any increase in PSA levels for two successive months results in cessation of their hormone replacement therapy. Of the several dozen patients that meet this criteria and have received testosterone replacement therapy, none have had a rise in their PSA or evidence of recurrence of their prostate cancer.

Bottom Line: Today, most urologists throughout the world, myself included, are comfortable using testosterone in men without the fear of causing prostate cancer, and in the US a majority will now offer testosterone treatment to some men previously treated for prostate cancer.  This revolutionary change in medical beliefs and practice resulted directly from the work of Dr. Morgentaler, who became a David against Goliath and was relentless in his pursuit of scientific truth and making it possible for some men who have prostate cancer with documented hypogoandism to receive hormone replacement therapy.

Screening For Prostate Cancer-What You Need To Discuss With your Doctor

September 22, 2014

Prostate cancer remains the most common cancer in men and the second most common cause of death in men due to cancer in men. Because of advanced treatments, curing prostate cancer has become more common. There now are more than 2.5 million survivors in the United States. Still, many men suffer from side effects after treatment, which may be a deterrent to obtaining care or even discussing the matter with a doctor. But early diagnosis and appropriate treatment will provide the best outcomes. I suggest that men should discuss the pros and cons of screening with their doctors as they approach 50. This blog will provide you with the information you need to discuss with your doctor.

Treatment options for prostate cancer

The treatment options for prostate cancer have improved significantly over the years. There are three basic choices available to treat localized prostate cancer. These include surgical approaches, most importantly robotic prostatectomy (i.e., robot-assisted laparoscopic surgery); various types of radiation treatments including brachytherapy (placing radioactive seeds in the prostate gland); and active surveillance. Most common long-term side effects of any treatment for prostate cancer are related to urinary issues, including incontinence (difficulty controlling urination), urgency and frequency, as well as sexual problems (erectile dysfunction).

 

Side effects from treatment

Although these side effects are not necessarily harmful in terms of longevity, obviously if these problems occur they will have a significant effect on one’s quality of life. Fortunately, with the advent of robotic surgery and brachytherapy, these side effects are greatly reduced. The incidence of long-term urinary incontinence is less than 5 percent, and preservation of sexual function is as high as 70 percent to 80 percent. The patient’s pre-treatment health and age will certainly have an effect on the post-treatment outcomes.

Many of these side effects will improve with time. It may take as long as six months for urinary incontinence to resolve after surgery. It may take longer, usually six months to a year, for return of normal sexual function after surgery. After radiation treatment, these urinary issues (including frequency and urgency) usually will resolve in a shorter period of time, although the sexual problems tend to occur in a delayed fashion, usually presenting at six months to 1 year after radiation. Certainly if either of these problems persist, it is best to be treated by one’s urologist. There are several treatments for incontinence/ including medication, urethral injections and, if necessary, surgical correction. There is also a broad array of options to treat impotency. Again, the spectrum will range from medical intervention to ultimately surgical correction if necessary.

Follow-Up After Treatment For Prostate Cancer

Because of the advances in urology, cure rates for localized prostate cancer have become extremely high, approaching 90 percent. Continued follow-up is quite important. Usually, men should be seen every six months for the first five years after treatment and then yearly after that. The follow-up usually includes a physical exam as well as continuous monitoring of the patient’s PSA blood levels. Further testing may be necessary if the PSA levels do start to increase. Additional treatments may be necessary if there appears to be a recurrence. It is quite important that this be done at an early point in time for more successful outcomes.

Get Support From Support Groups

There are prostate cancer support groups available. It is often quite helpful to hear that other men have gone through similar issues during their recovery. Other patients with similar problems are a great resource for information. These support groups are generally found through various websites, including the Prostate Cancer Foundation and the American Urological Association. Also the Mercy website can be used as a link.

Bottom Line: Prostate cancer if detected when it is confined to the prostate gland is curable. The best screening device is an annual exam for men after age 50 and a PSA blood test. Before getting the blood test, talk to your doctor about the diagnosis and the treatment so that you know the consequences of prostate cancer screening.

PSA Screening-What You Need To Know Before Being Tested

September 8, 2014

Prostate cancer is the 2nd most common cancer in men in the US, affecting about 1 in 6 men in his lifetime. It is the 2nd leading cause of cancer death in men, and almost 2 out of every 3 prostate cancers are found in men age 65 or older.

Screening can help find prostate cancer early.
Most insurance providers cover annual PSA tests for men ages 50 and older. A PSA test is a simple blood test that may help find prostate cancer early before it has spread. Talk to your doctor about when you should begin screening. Some organizations recommended men who are at higher risk of prostate cancer, including African American men and men whose father or brother had prostate cancer, begin screening at age 40 or 45.

The US Food And Drug Administration (FDA) first approved prostate-specific antigen (PSA) testing to screen asymptomatic men for prostate cancer in the early 1990s. In the decade prior to this approval, 5-year survival rates from the cancer stood at around 70-75%. By 1998, it had increased to 98.2%.

Although some health care experts have hailed PSA testing as the best available method to screen men for prostate cancer, there has been long-standing debate surrounding its use in routine testing.

PSA testing can lead to many false-positive results, meaning men can be alerted to cancers that are not actually present. Furthermore, critics argue that the test can lead to over-diagnosis, causing many men to undergo treatment they do not need.

September is National Prostate Cancer Awareness Month. So what is the evidence for and against PSA testing for prostate cancer?

PSA is a substance made by cells in the prostate gland. During a PSA test, a clinician will take blood from the patient and send the sample off to a laboratory, where levels of PSA are measured by nanograms per milliliter (ng/mL).

High levels of PSA – usually 4.0 ng/mL or higher – can indicate the presence of prostate cancer, and a man with such levels is likely to need a biopsy to determine whether he has the cancer.

However, high PSA levels can also be a sign of less harmful conditions, such as prostatitis or infection of the prostate gland – or enlarged prostate or benign enlargement of the prostate gland, a condition that can cause urination and bladder problems. Furthermore, the PSA test is unable to determine the difference between aggressive and benign prostate cancers. This is where concerns about the test’s accuracy come into play.

Past research has estimated that between 17-50% of men diagnosed with prostate cancer through PSA testing have tumors that would not have resulted in symptoms throughout their lifetime.

This means many men may receive treatment for prostate cancer – such as surgery, radiation or hormone therapy – that they do not need, which can lead to serious side effects, including urinary incontinence and erectile dysfunction.

Reasons Not To Test or Screen For Prostate Cancer
Such factors have fueled recommendations against routine prostate cancer screening. In 2012, the US Preventive Services Task Force (USPSTF) led the way by issuing a recommendation against PSA-based screening for prostate cancer for men of all ages who do not have symptoms.

Prostate cancer is a serious health problem that affects thousands of men and their families. But before getting a PSA test, all men deserve to know what the science tells us about PSA screening: there is a very small potential benefit and significant potential harms.

The American Cancer Society (ACS) does not provide guidelines that back routine PSA testing for prostate cancer. Instead, they state that “men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer.”

ACS suggest that a patient’s discussion with their health care provider about prostate cancer screening should start at age 50 for men who are at average risk of the disease and who are expected to live 10 years or more, while the discussion should take place at age 40 for men at high risk of prostate cancer.

The American Urological Association and the American College of Physicians have similar recommendations.
But despite recommendations against routine prostate cancer screening for men with no symptoms, many health care professionals believe PSA testing is crucial for preventing deaths against the disease.
Since PSA screening became routine in the 1990s, prostate-cancer mortality rates have declined by nearly 40%. I think PSA testing is the most likely explanation.

Without routine PSA testing, an additional 17,000 men every year would be diagnosed with advanced prostate cancer. We know that not all these men would be cured if detected earlier but PSA testing dramatically improves the odds that prostate cancer will be found before it becomes incurable.

Many men with prostate cancer feel that having a PSA test meant their cancer was diagnosed at a stage when it could be treated, and they would like all men to be able to benefit like they feel they have. As a result there have been calls for a screening program for prostate cancer using the PSA test to be introduced.

The European Randomised Study of Screening Prostate Cancer (ERSPC), launched in 2003 to determine the effect of routine testing on prostate cancer death rates.

Routine screening can lead to over diagnosis in around 40% of cases, which can lead to overtreatment and common side effects.

The results of another study – the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial – found that between 1993 and 2001, PSA-based screening for prostate cancer appeared to have no mortality benefits compared with a digital rectal examination.

With such conflicting studies on PSA testing for prostate cancer, it is no wonder that health organizations appear to be sitting on the fence when it comes to recommendations for such screening.

Dr. Otis Brawley, chief medical officer at the American Cancer Society stated that the majority of individuals are unaware of what the current recommendations are when it comes to prostate cancer screening.

Virtually every organization recommends men be informed of the documented harms and potential benefits of screening and be allowed to make a decision about being screened. Some may reasonably choose screening and make the decision about treatment after diagnosis. Even the USPSTF statement – which starts out recommending against routine screening – is consistent.

By looking at all available evidence for and against PSA testing for prostate cancer screening, it seems impossible to reach a firm conclusion about whether the test should be routinely offered to men or not.
If the test could distinguish between aggressive and harmless prostate cancers, routine screening would not be an issue, as the risk of overtreatment would be reduced. But of course, more research is needed to reach this point.

The US Food And Drug Administration (FDA) first approved prostate-specific antigen (PSA) testing to screen asymptomatic men for prostate cancer in the early 1990s. In the decade prior to this approval, 5-year survival rates from the cancer stood at around 70-75%. By 1998, it had increased to 98.2%.

Although some health care experts have hailed PSA testing as the best available method to screen men for prostate cancer, there has been long-standing debate surrounding its use in routine testing.

PSA testing can lead to many false-positive results, meaning men can be alerted to cancers that are not actually present. Furthermore, critics argue that the test can lead to over diagnosis, causing many men to undergo treatment they do not need.

I suggest that each patient being screened understands what is known about PSA screening and makes the personal decision that even a small possibility of benefit outweighs the known risk of harms.

They say a patient’s discussion with their health care provider about prostate cancer screening should start at age 50 for men who are at average risk of the disease and who are expected to live 10 years or more, while the discussion should take place at age 40 for men at high risk, i.e., if you have a close relative with prostate cancer or if you are of African-American.

The American Urological Association and the American College of Physicians have similar recommendations.

Bottom line: PSA screening isn’t for every man. However, every man should have a discussion with his doctor and see if PSA testing is appropriate for him.

Preventing Prostate Cancer

September 4, 2014

Prostate Cancer is a disease of aging and at this time there is no vaccine or sure fire way to completely prevent prostate cancer. However, there are steps you can take to reduce your risks.

• Advanced age increases your risk. Despite this, prostate cancer is not an “old man’s disease:” 35 percent of those affected are younger than 65.
• Family history may play a role. A strong family history of prostate cancer can increase your chances of developing the disease. While these factors are beyond our control, having awareness of increased risk can motivate us to focus on the areas we can affect.
• If there are factors that put you at higher risk, it’s important to be vigilant in areas you can control, including regular screenings. Talk with your doctor about the pros and cons of prostate screening. For African-Americans or those with a family history of prostate cancer, ask if screening should begin earlier.
1. Eat healthy. Avoid foods high in sodium, saturated fat, cholesterol, refined sugar and trans fat, which contribute to cancer risk. Instead, choose foods high in Omega-3 fatty acids (salmon, almonds) and monounsaturated fats (olive oil, peanuts) as well as fruits, vegetables and whole grains. Eating right doesn’t just lower your risk for prostate cancer, but prevents weight gain and improves your overall health.

2. Be active. Participate in 75 minutes of vigorous activity, or 150 minutes of moderate activity, weekly. This can include walking, swimming, biking or any exercise your doctor recommends.

3. Get screened. The National Comprehensive Cancer Network recommends baseline PSA screening for healthy men ages 50 to 70 every one to two years, and a majority of the panelists recommend baseline testing for men ages 45 to 49, too especially for men with a family history of prostate cancer or are of African American heritage.

Bottom line: Prostate cancer affects 250,000 men each year and causes 40,000 deaths making it the second most common cause of cancer death in men. Eating a healthy diet, exercising regularly and getting tested with a digital rectal exam and a PSA test on a regular basis is the best prevention strategy available today.

Prostate Cancer –Management of Low Risk Disease*

July 27, 2014

Prostate cancer remains one of the most common cancers in men with 250,000 new cases each year and causes nearly 40,000 deaths each year. Like most other cancers there are shades of gray and not all cancers need to have treatment. This blog will discuss the use of androgen deprivation therapy and when it might used in men with advanced prostate cancer.

There’s nothing like an elevated prostate specific antigen (PSA) test result to strike fear into even the most unflappable and courageous of men. That’s because elevations in PSA in the blood can point to the presence of prostate cancer. On the other hand, elevated PSA can also indicate prostatic enlargement or inflammation of the prostate. However, an elevated PSA test result, combined with a digital rectal exam and a 12-core prostate biopsy to remove small pieces of prostate tissue from the gland, will provide a very good idea as to whether a man has cancer or not.

About 40 to 50 percent of the 241,000 men expected to be diagnosed with prostate cancer this year will have a suspicious PSA score and a Gleason score of 6 out of 10, which is based on the prostate biopsy. A Gleason score of 6 is an indicator of a very favorable or low-risk disease, a disease that is treatable and curable — if, in fact, a man chooses to treat it.

Facing treatment decisions. Once a man has a prostate cancer diagnosis, he then has to choose what type of treatment he wants, which can include surgery or radiation therapy; men with low-risk cancer can also opt for active surveillance, or close monitoring without any immediate treatment. However, these men have to have a digital rectal exam and PSA test and possibly a repeat biopsy on a regular basis.

The good news is that low-risk prostate cancer — meaning low grade and low stage with a PSA below 10 ng/mL — grows slowly, if at all. Therefore, a man should be sure to discuss with his doctor whether he really needs to undergo any therapy to treat his cancer. That’s because in the majority of cases the answer will be “not now.”

What we have learned over the years with low-grade cancer is that sometimes the best option is no treatment whatsoever. And that includes treatment with androgen deprivation therapy, or ADT.
Earlier this summer, I came across a study in JAMA Internal Medicine that reminded me that many men with low-risk prostate cancer are still being offered primary ADT to treat their cancer, something that we would not recommend at Johns Hopkins. The reason: ADT offers no survival benefit for men with low-risk cancer and it causes significant side effects, including osteoporosis, diabetes and decreased libido.

Androgen deprivation therapy (ADT)–also called hormone deprivation, or hormonal or androgen ablation–is effective at turning off the body’s supply of male hormones, which prostate cells need to grow and develop. When the supply is shut off by drugs or by removing the testes, a portion of the cancer dies, tumors generally shrink, and PSA levels drop.

It’s androgens, or male hormones, that stimulate the growth of prostate tumors. The two most common androgens are testosterone and dihydrotestosterone (DHT). Since the Nobel Prize-winning discovery by Dr. Charles Huggins of the University of Chicago that prostate tumors depend on these hormones to grow, reducing androgen levels or blocking the action of androgen (androgen suppression) has become the standard of care for men with cancer that has spread beyond the prostate (metastasized) to the bones and other organs. There has also been increasing interest in using it in men whose PSA level has begun to rise after treatment with surgery or radiation (“biochemical recurrence,” an early sign that the cancer has not been eradicated).

Most urologists typically wait until there is evidence of metastatic disease before starting with ADT. There is an exception, however, and that is when we see a rapid PSA doubling time (less than six months) — because this provides indirect evidence of micrometastic disease that will develop in the next few years.

While ADT plays a significant role in the treatment of advanced prostate cancer, it has no role in the treatment of older men with low-risk cancer. Yet primary ADT is nevertheless being prescribed for one in eight men over age 65 diagnosed with localized prostate cancer.

The JAMA article. In the JAMA Internal Medicine study conducted by Grace L. Lu-Yao, Ph.D., a cancer epidemiologist at the Rutgers Cancer Institute of New Jersey and professor of medicine at Rutgers Robert Wood Johnson Medical School, more than 66,000 older men with low-risk prostate cancer were followed for up to 15 years. Dr. Lu-Yao reported that those men who received ADT lived no longer on average when compared with men who did not receive the therapy.

Prescribing ADT for these low-risk patients may decrease the high anxiety level that a patient may have due to his cancer diagnosis, however, it is necessary to note that such treatment may carry more risk than benefit. ADT helps reduce anxiety by quickly dropping PSA levels into the undetectable range, so the doctors may feel that they are doing something positive for their patients. However, ADT may not really be in the patient’s best interest due to complex side effects. The doctor should really be talking to patients with low-risk disease about pursuing active surveillance, not ADT.

There are serious potential risks associated with ADT, including coronary heart disease, and the associated high costs of the medications, the use of primary ADT should be limited to patients in the high-risk cancer group who are not suitable for, or opt not to receive, primary therapy — surgery or radiation — that has the potential to cure.
The side effects associated with ADT. In general, hormonal therapy will cause significant side effects after several months of treatment. Long-term side effects of ADT may include one, some or all of the following:
• Anemia
• Coronary heart disease
• Decreased energy
• Decrease in mental acuity
• Depression
• Diabetes
• Erectile dysfunction
• Hot flashes
• Loss of muscle mass
• Osteopenia
• Osteoporosis

Bottom Line: Many men with prostate cancer who have low risk disease or who have recurrence after treatment with radiation or surgery. This is usually detected by a rising PSA after treatment for prostate cancer that is confined to the prostate gland. These men should have a discussion with their urologists and discuss if androgen deprivation therapy is really in their best interests and that the benefits vs. the side effects are worth the treatment with androgen deprivation therapy.

*This blog was modified from the Johns Hopkins Newsletter, July 2014

PSA Elevation After Treatment For Prostate Cancer

July 24, 2014

Prostate cancer represents the second most common cancer in men following lung cancer. Prostate cancer will be diagnosed in nearly 250,000 men annually and causes nearly 40,000 deaths each year. If you already have had prostate cancer treatment, changes in PSA levels can tell whether treatment is working.

After surgical removal of your prostate, your PSA levels should be undetectable. After radiation therapy, the PSA levels should drop and remain at low levels.
Signs that your cancer has returned may include one of these:
Three consecutive PSA rises above the lowest level over time
Confirmed rise of more than 2 ng/mL from your lowest level

The key is monitoring your PSA levels over time. A rapid rise suggests rapid cancer growth and the need for treatment. A very slow rise of the PSA can often be watched.
But PSA levels can also be somewhat confusing. For example, they can go up and down a bit for no reason. The PSA test is not precise, and minor changes from test to test are to be expected.
Low rises of PSA levels can’t predict your longevity or symptoms when you have cancer. But high or rapidly rising PSA levels can suggest future problems.
That’s why doctors take other factors into account when evaluating your situation. Talk with your doctor to get a better idea of what to expect, so the numbers don’t add to your anxiety.

Advanced Prostate Cancer and PSA Levels Over Time
If you have advanced prostate cancer that has spread outside the prostate, your doctor will be looking less at your actual PSA levels than at whether and how quickly PSA levels change.
Doctors use changes in PSA levels over time (called PSA velocity) to tell how extensive and aggressive your cancer is.

Your doctor won’t just look at one PSA reading at a time. He or she will confirm it with multiple tests over many months, especially after any radiation therapy. That’s because you can have a temporary bump in PSA levels for about one to two years after radiation treatment.
To determine how aggressive your cancer is and whether further treatment makes sense, your doctor may also consider your:
PSA levels before cancer
Grade of cancer or the Gleason score. The higher the Gleason score, the more aggressive the cancer.
Overall health and life expectancy
PSA Levels and Treatment for Advanced Prostate Cancer
Your symptoms and how long it takes for your PSA levels to double (PSA doubling time) affect decisions about how soon to try treatment such as hormone therapy.
Your doctor will look at how quickly or slowly PSA rises before deciding on which treatment to suggest. You may need continued monitoring before moving to a new treatment. Your doctor may suggest waiting for a while to delay the appearance of treatment-related side effects. Discuss with your doctor how to weigh these considerations.

PSA levels may also be useful in checking if your treatment for advanced prostate cancer is working after you have had:
Hormone therapy
Chemotherapy
Vaccine therapy
Treatment should lower PSA levels, keep them from rising, or slow the rise, at least for a while.
Doctors monitor PSA regularly based on the type of treatment you had first. For example, after hormone therapy, PSA should drop to a lower level quickly, i.e., within weeks. It may fall further over time as you continue hormone therapy.

Combined with symptoms and other tests, PSA tests can also show if it’s time to try another type of treatment.

Bottom Line: PSA is an imprecise test for diagnosing and monitoring prostate cancer. If the PSA rises quickly after treatment, whether it is surgery, radiation, or hormone treatment, this is of concern and you may need to have additional treatment. Speak to your doctor if you have any questions.

Vasectomy And Prostate Cancer-What’s the Risk

July 10, 2014

I often receive calls about the relationship between prostate cancer and vasectomy. There have been many studies that have looked into this relationship and this blog will shed some light on the issue and help men make an informed decision on having a vasectomy, one of the best methods of permanent contraception.

Men who had a vasectomy had a significantly greater risk of developing aggressive, potentially fatal prostate cancer, according to data from a 50,000-patient cohort study.
A recent study in the Journal of Clinical Oncology stated that the overall association between vasectomy and prostate cancer was modest.

The lead authors was quoted as saying, “I think we need to tell men that vasectomy has some risk with prostate cancer, may be linked, but we don’t know. It’s something they need to be aware of and monitored, but really, to me, this is not something that is such a strong association that we need to be changing the way we practice, either prostate cancer screening or vasectomy.”
Studies dating back to the early 1990s have yielded conflicting results about the association between vasectomy and prostate cancer. Some studies have shown as much as a twofold increase in the risk of prostate cancer after vasectomy, whereas others showed no association, the authors noted.

During follow-up through 2010, 6,023 participants had newly diagnosed prostate cancer, including 811 lethal cases. The data showed that 12,321 of the men had vasectomies. The primary outcomes were the relative risk (RR) of total, advanced, high-grade, and lethal prostate cancer, adjusted for a variety of possible confounders.

Vasectomy did not have a significant association with low-grade or localized prostate cancer.

The study adds information to the discussion and controversy surrounding vasectomy and prostate cancer but leaves many questions unanswered. Use of transurethral resection of the prostate, statins used to treat elevated cholesterol levels, selenium, and a number of other factors can influence prostate cancer risk.

The study added little information that goes beyond what previous studies had shown, said Gregory Zagaja, MD, of the University of Chicago. The study suffered from the same limitations of studies that came before it.

Multiple experts state that no consensus exists about potential biological explanations for reported associations between vasectomy and prostate cancer or whether the association is biologically plausible.

Bottom Line: There is a modest risk of prostate cancer in men who undergo a vasectomy. All men, whether or not they have had a vasectomy, need to have a regular PSA and digital rectal exam. For more information on this topic and the relationship between prostate cancer and vasectomy, speak to your doctor.