The New Skinny On Prostate Cancer Screening With the PSA Test

April 11, 2017

Prostate cancer remains one of the most common cancers in men and is the second most common cause of death from cancer in men.  (Lung cancer is still leading the list)  The American Cancer Society projects more than 161,000 new cases this year in the U.S., with about 26,730 deaths each year.  Prostate cancer accounted for 4.4% of all cancer deaths in the United States last year.

The U.S. Preventive Services Task Force, an independent and influential panel of experts, published new guidelines in early April 2017 for screening for prostate cancer for the first time in five years.

The new recommendations: Men ages 55 to 69 should “make an individualized decision about prostate cancer screening with their clinician.” That’s updated from a blanket recommendation in 2012 for no routine screening at any age.

The task force also recommends that those men older than 70 shouldn’t undergo PSA screening.

Now doctors are saying that the older recommendation in 2012, i.e., not to screen for prostate cancer likely resulted in deaths that could have been avoided..

The PSA test is a simple blood test that determines levels of the prostate-specific antigen protein, and elevated PSA can be a sign of prostate cancer. But elevated PSA can also be caused by other conditions, like inflammation of the prostate or benign enlargement of the prostate gland.

The risk of potential harm of over-diagnosis has led to confusing recommendations for screening. Treatment for prostate cancer, including removal of the prostate and radiation, is associated with the side effects of incontinence and erectile dysfunction.

False positives can lead to unnecessary further testing or treatment, and many cases of prostate cancer are slow-moving and require watchful waiting rather than immediate treatment.  This means that the men with slow growing, non-aggressive cancer can be followed with a digital rectal exam, frequent PSA testing, and perhaps additional prostate biopsies.

So how useful is PSA screening? According to the New England Journal of Medicine, studies imply that 1 prostate cancer death is averted per 1,000 men screened several times each, and followed for 10 to 15 years.

On the flip side, the authors reported, data show about 35 over-diagnosed cases per 1,000 men screened.

Some groups are at higher risk for prostate cancer, including African-American men and those with a family history of the disease.

Bottom Line: It is my recommendation to my patients 55-69 they have a discussion with their physician and weigh the benefits vs. the harms of PSA testing.  With that discussion the men can make the best choice for themselves, together with their doctor.

ED and Good Health

April 10, 2017

Many men are unaware of the relationship between ED (impotence) and their overall health.  ED not only include ability to engage in sexual intimacy but also includes problems with libido, and abnormal ejaculation.

ED is defined as the consistent inability to attain or maintain a penile erection of sufficient quality to permit satisfactory sexual intercourse.

The process of diagnosis and treatment begins with a careful sexual history.  Men with a sexual problem will probably be asked:

  • Are you currently having sexual relations?
  • With whom do you have these relations (men, women, or both, and how many partners)?
  • When was the last time you had intercourse?
  • Are you satisfied with the quality and frequency of your sexual experiences?

The answers will clarify what aspects of sexual dysfunction are occurring and inform the rest of the evaluation. If libido is intact but ED is a complaint, then what underlying medical conditions or medications may be contributing to the problem? If libido is affected, are there significant psychologic or emotional contributing factors that need to be addressed as well as measuring the serum testosterone level.

Although sexual problems are not necessarily caused by aging; it is true that aging is associated with an increase in sexual issues. As early as 40 years of age, up to 40% of men report some impaired sexual function.  Inability to attain or maintain an erection consistently for satisfactory intercourse was reported in 67% of males over 69 years of age in another study.  Testosterone decline is common with age. While this may play a hormonal role in sexual dysfunction, it is important to thoroughly evaluate all possible causes before initiating testosterone replacement therapy for sexual dysfunction alone.

Similarly as men age, interest in sex may decline due to lack of novelty as well as an increase in stress that often occurs in older men. Fatigue, lack of privacy in the family setting, and unresolved anger with a partner may all be determinants of sexual problems in the older male. More critically, loss of interest in sexual activity and loss of libido may be manifestations of depression.  Depression can cause sexual problems, but the reverse may also be true.

In addition to these factors, diabetes, blockage of the blood vessels, and adverse effects from medications, both prescribed and recreational (marijuana and cocaine) may all play roles in sexual functioning. Disease states such as hypertension, diabetes, heart disease, and obesity can affect the blood flow into the penis. Blockage in any of the major arteries feeding the blood supply to the penis can lead to inability to obtain and maintain an erection. Diabetes, for example, this can also affect the mechanism of erection and cause ejaculatory disorders such as backward ejaculation of the fluid to the bladder instead of out of the tip of the penis at the time of orgasm.

Medications that are often identified as causes of erectile disorder which include medications used to treat depression, blood pressure lowering medications, cholesterol medications, and drugs used to treat prostate cancer.  Excessive alcohol use is the most common substance that can lead to ED, though cocaine, heroin, and marijuana have all been linked as well.

Bottom Line:  ED is a common problem affecting millions of middle age and older American men.  The diagnosis can often be attributed to underlying disease states.  A careful history and physical examination will help to elucidate the problem and start you on the road to successful treatment.

The Latest Advice on Screening for Prostate Cancer

April 5, 2017

The concept of screening for prostate cancer is a moving target. Screening for this common cancer in men has undergone significant changes in the past ten years. This blog is intended to provide you with advice on whether you should participate in prostate cancer screening.

 

Another progress being made is that men with early-stage tumors have been spared the side effects of treatment, such as erectile dysfunction (impotence) and urinary incontinence, which can be devastating. A recent report notes that 15 years after diagnosis, that 87% of men who underwent surgery and 94% of men who had radiotherapy were unable to engage in sexual intimacy.

 

So what do you need to know about prostate cancer screening?

 

Talk to your doctor about obtaining a PSA tests if you are at high risk for prostate cancer. These include African American men who are twice as likely to be diagnosed with prostate cancer and have an aggressive form of the disease and 2.4 times more likely to die from it than Caucasian men.

 

Men with a family history of prostate cancer are twice as likely to have prostate cancer and to die from it.

 

New tests for prostate cancer

We have been looking for a test that will better predict prostate cancer than an elevated PSA level. There are four new tests to enhance the diagnosis of prostate cancer.

 

A urine test, PCA3 looks for the presence of a specific prostate cancer gene. This test is more accurate than the PSA test in deciding whether a man needs a prostate biopsy.

 

The Prostate Health Index (PHI) blood test evaluates three different components of PSA to determine whether the elevated PSA level is due to infection, benign prostate disease or possibly prostate cancer.

 

The 4K score blood test is similar to the PHI test but looks at four components which can predict a man’s risk of developing prostate cancer.

 

Finally, the prostate MRI or magnetic resonance imaging test which can accurately diagnose aggressive prostate cancer.

 

If any of these four tests are positive, then the next step is a prostate biopsy.

 

So what is my “bottom line” on prostate cancer screening? I suggest a baseline PSA test for all men at age 50 and for higher risk patients at age 45. Men with very low PSA levels, less than 0.7ng\ml at baseline can have the PSA test every 5 years, and those 60 and older with levels less than 2.0ng\ml or lower may be able to avoid future PSA testing for the rest of their lives….as long as they remain symptom free. If you have any questions, check with your doctor.

Body Builders Using “Juice” Beware!

March 30, 2017

I don’t know of any physicians who would condone the use of anabolic steroids in men with normal testosterone levels whose only complaint is desire to increase their muscle mass or their athletic performance.  The use of anabolic steroids in young men is fraught with danger and can result in permanent hormone deficiency and permanent infertility.

Testosterone was first identified in 1935 as responsible for its masculinizing effects along with the effect of increasing lean muscle mass.

However, recently the illicit use of performance enhancing drugs has become an issue for athletes and those men wishing to increase their athletic performance, their strength and muscle mass.   It is estimated that there are 3 million anabolic steroid users and abusers.  And now we have found that nearly 5-6% of middle and high school students have or are using anabolic steroids.

These anabolic drugs are now identified to negatively affect the pituitary glands hormones that stimulate the testicle to produce testosterone and result in prolonged reduction of natural testosterone production and even permanent decrease in testosterone production for many months and even permanently in men who have used and abused anabolic steroids.  Most men will return to baseline natural production of testosterone in 1-2 years after discontinuing the use of anabolic steroids.

There are numerous reports of profound suppression of testosterone in nearly half of all men who have used anabolic steroids.  Because anabolic steroid can have a profound reduction in sperm production, men should understand the consequences of anabolic steroid use.  That is, if they want to father a child, they need to stay farther away from anabolic steroids.

Bottom Line: Anabolic steroid abuse can affect a man’s production of testosterone and may cause permanent reduction in testosterone production by a man’s testicles.  I suggest that all men who might consider using anabolic steroids to take this into consideration before making a bad choice that may affect their health and well being forever.

 

Low T-Review of New York Times Editorial, March 28, 2017

March 29, 2017

 

Low testosterone affects millions of American men.  Testosterone prescriptions in the United States nearly doubled in recent years from 1.2 million in 2010 to 2.2 million in 2013. Testosterone replacement is not the panacea to restore a middle aged man’s fountain of youth.  However, testosterone replacement can improve a man’s sex drive or libido, can increase his energy level and does improve bone strength and a protector for osteoporosis in men.

That’s the good news.  The bad news is that a single study comparing testosterone gel to placebo for one year found a “buildup of noncalcified plaque” in the coronary arteries of the men treated with testosterone.  However, other studies have not demonstrated any increase in heart problems in men using testosterone.

Although the positive changes were modest in the testosterone group there was a significant improvement in men’s mood in the group using testosterone gel.  The study also pointed out that older men with low testosterone levels often have other chronic health conditions, like obesity, than can affect hormone levels but these can often be managed by lifestyle changes such as an exercise program and diet.

It is important to mention that the results of the recent study do not support the promise implied by advertisements for testosterone that using it “will make you stronger and fitter,” though many men said they simply “felt better” while on the drug, and some improvements in walking could be seen when findings were analyzed.

Again, I would like to emphasize that testosterone has no place in men using these hormones for bodybuilding purposes.  At the present time use of testosterone is snot approved by the FDA for bodybuilding purposes.

The Bottom Line: Hormone replacement therapy has a role in men who have symptoms of low T and documented low blood levels of testosterone.  All men who receive testosterone need to have close follow up with PSA testing, a digital rectal examination and a blood count to check for overproduction of red blood cells.

Testosterone Replacement-Relationship With Heart Disease

March 27, 2017

Much has been written about the use of testosterone in men with symptoms of low T and documented low levels of testosterone.  One of the issues is the use of testosterone replacement therapy and its impact on cardiovascular health.

First, there have been documented trials that demonstrated clinically improvements in bone density and low blood count or anemia.  Another recent study demonstrated an impressive reduction in cardiovascular events such as heart attack and stroke in men taking testosterone for low T levels.

A two year study was conducted comparing testosterone replacement therapy using topical gels containing testosterone to placebo that had gel only and no testosterone. At one year after starting the study, there were no heart attacks, strokes, or deaths in either group. At two years there were more heart attacks and strokes in the placebo group (nine events for placebo versus two events for testosterone).  The study concluded that testosterone replacement may be cardioprotective or can protect your heart.

A key additional finding was significant improvement in bone density and strength in men treated with testosterone.

Bottom Line:  These new, exciting results provide even more evidence to support the importance of using testosterone replacement therapy in men with low levels of testosterone and who are symptomatic from their decrease in testosterone levels.

Non-Medical Solution For GERD-Heartburn

March 26, 2017

Millions of Americans suffer from heartburn, indigestion, or GERD, an acronym for gastro esophageal reflux. This is a condition where acid stomach contents backwards from the stomach into the lower esophagus which is the tube from the mouth to the stomach. GERD is also associated with a dry cough, sore throat, hoarseness, burping, abdominal bloating, and difficulty swallowing. The symptoms are often accentuated when a man or woman lies down which allows the acid stomach contents to go backwards into the esophagus producing the burning and pain associated with GERD.

Many who suffer from GERD take medications called proton pump inhibitors. These medications while preventing GERD also cause nutrient deficiencies, joint pain, infections, heart attacks, and even dementia.

Nearly 15 million Americans use proton pump inhibitors. However, there are non-medical solutions that don’t require the medications and don’t expose those with GERD to the side effects of the medications.

One of the risk factors for GERD is obesity. Those men and women who have a BMI or body mass index greater than 30 are twice as likely to experience GERD. Therefore, weight loss is one of the best and easiest ways to decrease GERD and not use any medication.

Other risk factors include smoking and excessive use of alcohol. Both alcohol and nicotine in cigarettes relax the muscles between the stomach and esophagus and allow the acid contents of the stomach to go backwards into the esophagus. Consequently, discontinuing the use of cigarettes and limiting the alcohol especially in the evening will help alleviate the symptoms of GERD.

Simple solutions include avoid eating large quantities of food at one time as this distends the stomach and causes the acidic content to reverse direction into the esophagus. Consider having five or six small meals a day instead of the standard three large ones. I suggest avoid exercising soon after consuming a meal. Also, if you experience GERD when laying down, then raise the head of the bed by six to eight inches.

Next in order of non-medical treatment of GERD is diet. Certain foods like coffee, onions, garlic, acidic fruit juices like grapefruit and orange juice, and chocolate are likely to precipitate GERD. Another caveat is to avoid high fat foods as they take time to digest and remain in the stomach for longer periods of tie. I recommend natural, unprocessed foods, especially lean protein foods like poultry, fish, egg whites, and low fat dairy products, whole grans, and non-acidic vegetables and fruits. High fiber foods are also helpful. I suggest consuming a pound of vegetables a day, half of which are cooked and the other half eaten raw as well as a pound of raw fruit a day. This will add ample amounts of fiber to your diet.

Bottom line: GERD is a common condition that is often treated with medication, i.e., proton pump inhibitors. I suggest you try these non-medical solutions first before considering the use of medications.

Non-Medical Solutions to Raising Your Low T Level

March 23, 2017

I am often asked by patients what can a man do to raise his testosterone level without taking testosterone replacement therapy?  Here are a few suggestions that may be helpful.

  1. Exercise and lift weights

If you want to increase your testosterone levels, you will need to increase your exercise frequency. Regular exercise will not only help you by preventing different lifestyle related health problems, but it will also help you by boosting your testosterone levels. Men who regularly exercise have a higher testosterone levels. Even elderly men will also have higher testosterone levels if they regularly exercise.

  1. Reduce stress and cortisol levels

If you are suffering from long-term stress, it can increase the levels of cortisol hormone. If your cortisol levels are high, testosterone levels will decrease.

That’s why, you need to reduce stress as much as possible and which will also decrease the cortisol levels in your body. Regular exercise, whole foods, good sleep, balanced lifestyle and laughter can help you to reduce stress and also improve your overall health.

  1. Get more Vitamin D

Vitamin D offers several health benefits and it boosts testosterone naturally. If you consume just 3,000 IU of vitamin D3 per day, it can increase testosterone levels in the body by 25%.

You can get more vitamin D by increasing your exposure to sunlight regularly. You can also take a daily supplement of 3,000 IU of a vitamin D3 supplement.

4. Get Enough Sleep.

A lack of sleep affects a variety of hormones and chemicals in your body. This, in turn, can have a harmful impact on your testosterone.

The time honored goal is try for 7 to 8 hours per night.

5. Keep a Healthy Weight.

Obesity can have a deleterious effect on your testosterone levels.  Exercise and diet can improve your testosterone and also is good for your heart to avoid obesity.

6. Review Your Medications.

Some medicines can cause a drop in your testosterone level. These include: pain medications, steroids (prednisone), anabolic steroids such as those used by athletes and body builders, and anti-depressants.

7. Deep 6 the Supplements.

You may be bombarded with unsolicited snail mail and E –mail offering testosterone boosting supplements such as DHEA.  Let the truth be told, you are wasting your money as these supplements will not boost your testosterone.

Bottom Line:  Although these suggestions are helpful, they are just a step in the right direction.  For more information about testosterone replacement therapy, speak to your physician.

Diet and Exercise May Reduce Risk of Cancer

March 23, 2017

There isn’t a day that goes by that the Internet or the print media isn’t bombarding readers with a new diet that prevents cancer.

Every day, there are headlines that bombard readers with various diets that purportedly prevent cancer: “The Diet That Stops Cancer” and “Eating Your Way Out of Cancer.” But what do the hard data really say about lifestyle choices preventing cancer?  Studies have shown that the combination of healthy eating, not smoking, and regular exercise can reduce the risk of heart disease by 80 percent and of stroke and some cancers by 70 percent.

Although no diet has received conclusive evidence of presenting cancer, there are lifestyle choices such as exercise that support conclusions that they can serve as deterrent of cancer.  Even the American Cancer society recommends avoid being overweight and includes being physically active for at least 30 minutes every day.  They also suggest eating a mostly plant-based diet; limiting red meats and avoiding processed meats; limiting alcoholic drinks (two glasses of wine a day for men and one glass for women); and to protect against cancer (Table 1). Other recommendations include avoid sugary drinks, limit consumption of processed foods and eat more vegetables, whole grains, and legumes such as beans.  Limit salt intake to 1.5 grams per day and limit consumption of salty foods, chips, pretzles, smoked or cured meats like salami, baloney, and beef jerky.

Other Cancer Prevention Recommendations

To prevent breast cancer, the ACS recommends at least 150 minutes of moderate-intensity physical activity per week, alcohol intake of one or fewer drinks per day, and maintaining a body mass index (BMI) less than 25 kg/m2. In a study of 2905 women at high-risk for breast cancer, adherence to these three recommendations reduced the risk for breast cancer by 44%.

Perhaps this shouldn’t be all that surprising, given that BMI itself is a risk factor for cancer. Too much body fat triggers insulin resistance, raising levels of insulin and growth factors that promote cancer. Fat also increases estrogen production, which can fuel some cancers, and fat secretes enzymes that promote inflammation.

Numerous medical studies have concluded that avoiding adult weight gain confers protection against certain types of cancer, particularly among nonusers of hormone replacement therapy (HRT). The study found that for each 5-kg increase in adult weight gain, the relative risk was increased 11% for postmenopausal breast cancer among no or low HRT users; 39% and 9% for postmenopausal endometrial cancer among HRT nonusers and users, respectively; and 13% for postmenopausal ovarian cancer among no or low HRT users. For each 5-kg increase in men, the risk for colon cancer increased by 9%. The relative risk for kidney cancer comparing highest and lowest level of adult weight gain was 1.42.

In addition to lowering the risk of cancer, eating a diet that is high in fruits and vegetables is associated with a lower risk for all-causes of death and lower risk of dying of cardiovascular causes such as heart disease or stroke.

Bottom line on diet and exercise and cancer prevention:  Weight gain, lack of exercise, and high alcohol intake are the key factors for leading a healthy lifestyle and decreasing the risk of cancer.

 

 

The Semen Analysis: There’s Even an App for That!

March 23, 2017

The first examination for male infertility is a history followed by a physical exam.  Next comes the semen analysis, where a single drop of seminal fluid is examined under the microscope.  The semen is examined for the number of sperm, the motility of the sperm, and the shape of the sperm.  This test is performed after 48 hours of abstinence and the cost is $75-$150 depending on the sophistication of the lab performing the test.

Soon it is possible to have an accurate sperm count in the privacy of your home and will be as easy as a home pregnancy test.

Researchers have developed a device costing less than $5 to make that attaches to your cellphone and provides a quick and easy semen analysis. The results in early testing are just as accurate as the elaborate computer-assisted semen analysis machines costing tens of thousands of dollars in measuring sperm concentration, sperm motility, total sperm count and total motile cells.

The device uses an optical attachment for magnification and a disposable microchip for handling the semen sample. With two lenses that require no manual focusing and an inexpensive battery, it slides onto the smartphone’s camera. Total cost for manufacturing the equipment: $4.45, including $3.59 for the optical attachment and 86 cents for the microfluidic chip that contains the semen sample.

The software is designed with a simple interface that guides the user through the test with onscreen prompts. After the sample is inserted, the app can photograph it, even create a video of the sperm motility and report the results in less than five seconds. The test results are stored on the phone so that semen quality can be monitored over time.  The results can be shared with the medical professional who is evaluating the man\couple for infertility.

Another application of the app is for men who have had a vasectomy and need to be certain that there is absolutely no sperm in the ejaculate following the procedure.  With this app, a man can perform his own semen analysis at home and email the result to the urologist to confirm permanent sterility

The Food and Drug Administration hopefully will approve the device within the next two years.

Bottom Line: Technology is making medical care easier and can be accomplished without being face to face with the doctor or even having to go to the doctor’s office.  This is the way modern medicine is going to be practiced.  Welcome to the new age of medical care.