Posts Tagged ‘PSA testing’

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.

Preventive Health For All Men

January 18, 2016

Do you know that most men spend more time taking care of their cars or planning a vacation than they do taking care of their health?  In the U.S., women live 5-7 years longer than men.  I believe one of the reasons is that women seek out regular medical care throughout their entire lives.  They see a obstetrician during child bearing years; they get regular mammograms; they obtain routine PAP smears and other preventive health measures for their entire lives.  Men, on the other hand, stop seeing a doctor around age 18 and never see the inside of a medical office until middle age.  During that time they can have high blood pressure, elevated cholesterol levels, diabetes, and prostate diseases.

But there are some things men, in particular, should keep in mind when it comes to maintaining their health:

Heart disease and cholesterol

According to the Centers for Disease Control and Prevention, about 200,000 people die each year from preventable heart disease and strokes, with men being significantly more at risk than women.

Men should begin screenings for these issues in their mid-30s.

Annual health examinations should begin at around age 50.  This should include a test for anemia, a cholesterol level, a chest x-ray if the man is a smoker, a PSA test for prostate cancer, and a blood pressure determination.

For those men with an elevated cholesterol level, they can lower the level by adhereing to  a healthy diet consisting less heavy in red meats and carbohydrates, and limiting alcohol consumption, i.e., 2 drinks\day. Men of all ages should also continue to stay physically active by incorporating aerobic activities, i.e., any activity that increases the heart rate for 20 minutes 3-4 times a week, into their lifestyle, as well as strength training.

Prostate health

There is some debate among health care professionals about when men should begin screening for prostate cancer. The U.S. Preventive Services Task Force and the CDC recommend against screening unless men begin experiencing the symptoms associated with prostate cancer. These include frequent urination, especially at night, pain during urination and difficulty fully emptying the bladder.

Prostate screening can begin earlier in life, around age 40, if there is a high risk for prostate cancer, such as family history, or bothersome lower urinary tract symptoms.

Testosterone

As men age, lowering testosterone levels can become another area men should monitor.  Significantly low testosterone levels can predispose a man to low bone mineral density with subsequent bone fractures, erectile dysfunction (impotence) and low energy levels.

Testing for testosterone levels is done through a blood test.

Bottom Line: these are the minimal preventive care that all men should consider around age 30-40.  Remember if it ain’t broke don’t fix it, may apply to your car, but not to your body.  You need to take preventive measures with your body just as you do with your automobile.

Menopause or Andropause-Not the “Pause” That Refreshes Either Women or Men

July 19, 2015

Around age 50 women have a drop in their hormones and enter into menopause. At about the same age men start experiencing a decrease in testosterone occurs. This is the male hormone that is responsible for sex drive, muscle mass, bone strength, and even erections. This condition in men is referred to as andropause and it affects millions of American men.

The symptoms of andropause include hot flashes, fatigue, night sweats, mood swings; all the fun things that females going through menopause may endure. Men lose one percent testosterone for every year past 30 but usually don’t develop symptoms until age 50. As testosterone decreases, estrogen increases. Abdominal fat causes excess estrogen and low levels of testosterone may also lead to prostate problems. Ever wonder why suddenly you are gaining weight around the middle? It could be your hormone levels are unbalanced.

The diagnosis is easily made with a blood test to measure the testosterone level. Men more than 50 years of age should also have a digital rectal exam to check their prostate gland and a PSA test which is a screening test for prostate cancer. Treatment options include testosterone replacement therapy. This can be administered with self injections of testosterone, topical gels, or the insertion of testosterone pellets under the skin.

Bottom Line: Testosterone deficiency in middle age and older men affects millions of American men. The diagnosis is easily made and effective treatment is available. You don’t have to suffer this common condition. Help is available. See your doctor.

Myths and Misinformation On Prostate Cancer

June 10, 2015

Prostate cancer is the second most common cancer in men, following lung cancer, with 250,000 new cases discovered each year. There are many areas of confusion about prostate cancer. Let me debunk a few of these myths.

Myth 1: Prostate cancer surgery will end your sex life and cause urine leakage.
Fact: Your surgeon may be able to spare the nerves that help trigger erections. Then you will probably be able to have an erection strong enough for sex again. But it may be a while. Recovery can take from 4 to 24 months, maybe longer. Younger men usually recover sooner.
If you still have trouble, ask your doctor about treatments for erectile dysfunction. Cialis, Levitra, and Viagra are common medications that can help. Your doctor will tell you if these are right for you.

Other prostate cancer treatments, such as radiation and hormone therapy, also can affect your sex life. Urine leakage may occur after surgery, but it’s usually temporary. Within a year, about 95% of men have as much bladder control as they did before surgery.

Myth 2: Only elderly men are at risk of prostate cancer.
Fact: Prostate cancer is rare for men under 40. If you are concerned, ask your doctor if you need to get tested earlier. Age isn’t the only factor. Others risk factors include:
Family history. If your father or brother had prostate cancer, your own risk doubles or triples. The more relatives you have with the disease, the greater your chances of getting it.
Race. If you are African-American, your risk of prostate cancer is higher than men of other races. Scientists do not yet know why.
You may want to discuss your risks with your doctor so you can decide together when you should be tested for prostate cancer with a screening PSA test and a digital rectal examination.

Myth 3: All prostate cancers must be treated.
Fact: You and your doctor may decide not to treat your prostate cancer. Reasons include:
Your cancer is at an early stage and is growing very slowly.
You are elderly or have other illnesses. Treatment for prostate cancer may not prolong your life and may complicate care for other health problems.
In such cases “active surveillance” may be an option to consider. This means that your doctor will regularly check you and order tests to make sure your cancer does not worsen. If your situation changes, you may decide to start treatment.

Myth 4: A high PSA score means you have prostate cancer.

Fact: Not necessarily. Your PSA could be high due to an enlarged prostate or inflammation in your prostate. The PSA score helps the doctor decide if you need more tests to check for prostate cancer. Also, your doctor is interested in your PSA score over time. Is it increasing, which could be a sign of a problem? Or, did it decrease after cancer treatment, which is great.

Myth 5: If you get prostate cancer, you will die of the disease.
Fact: You’re likely live to an old age or die of some other cause. That doesn’t mean checking for prostate cancer is not important. Most men with prostate cancer die with the cancer and not from it.

Bottom Line: I hope this article puts the perspective of prostate cancer back in its proper perspective. The diagnosis is common and help is available for most men with prostate cancer.

PSA Test For Diagnosis of Prostate Cancer-The Test That Just Might Save Your Life

March 12, 2015

The value of prostate-specific antigen (PSA) screening for prostate cancer is the subject of much debate today. Results from a large long-term European study provide important insight. The study was published in Lancet, which is a prestigious European medical journal.

Over 13 years, men who were offered PSA screening had a 21 percent lower risk of dying of prostate cancer than their counterparts who weren’t offered screening. Stated another way, PSA screening prevented one death for every 27 cases of prostate cancer it detected.

In spite of these results, there is no one-size-fits-all screening strategy. All men and their doctors should weigh the benefits and risks of screening based on the man’s individual circumstances and preferences.

Bottom Line: These findings provide confirmation that prostate cancer-related deaths are lower in men who are screened. I recommend annual PSA testing until age 75 and discontinue testing as prostate cancer is a slow growing malignancy and older men will often die WITH prostate cancer rather than FROM it.

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.

Medical Tests That You Can Do Without

March 11, 2014

I just had my annual physical examination. I am without any symptoms; take a baby aspirin and a vitamin; have no co morbid conditions. I asked myself did I really need a chest x-ray when I am exposed to so much radiation during my work at the hospital or did I need an EKG with no symptoms and a negative family history? I found my answer in a recent AARP article about “10 Tests To Avoid”.

1. Nuclear stress tests, and other imaging tests, after heart procedures
If you have had heart bypass, stent or other heart procedure, you don’t need nuclear stress test or other tests that their hearts are beating strong and the results rarely change the plan of management. Instead, patients and doctors should focus on what does make a difference in keeping the heart healthy: managing weight, quitting smoking, controlling blood pressure and increasing exercise.

2. Yearly electrocardiogram or exercise stress test
Someone at low risk for heart disease could be 10 times more likely to get a false-positive result than to find a true problem with their heart. The stress test could lead to unnecessary heart catheterization and stents. Instead, it is important to have your blood pressure and cholesterol checked at least once a year. And if you’re at risk for diabetes, have your blood glucose level checked as well.

3. PSA to screen for prostate cancer
Cancer is always scary, but the PSA test often finds slow-growing cancers that won’t kill men. An estimated 75 percent of tests that show high PSA levels turn out to be false alarms.
The American Urological Association, of which I am a member, supports the use of PSA testing, but should be considered mainly for men ages 55 to 69. I also believe that no testing is required in the man without any symptoms if the man is more than 75 years of age. However, men with a positive family history of prostate cancer and African American men should have an annual PSA test and a digital rectal examination.

4. PET scan to diagnose Alzheimer’s disease
In the last few years, doctors have begun using PET scans with a radioactive dye to look for beta-amyloid protein that is found in the brains of people with the Alzheimer’s disease. Even if a PET scan could accurately diagnose the disease, it’s untreatable. If you’re concerned about your memory, the better course is to have a complete medical evaluation by a doctor who specializes in diagnosing and treating dementia.

5. X-ray, CT scan or MRI for lower back pain
Back pain is incredibly common — 80 percent of people will suffer from back pain some time in their lives. It can be both excruciating and debilitating. Naturally, people want to know what’s wrong. Here’s the catch: The best imaging machines in the world often can’t tell them. Many older people with no back pain can have terrible-looking scans.
Most back pain goes away in about a month and imaging tests tend to lead to expensive procedures that often don’t help or shorten recovery. If you don’t feel better in a month, talk to your doctor about other options such as physical therapy, yoga or massage. But if your legs feel weak or numb, you have a history of cancer or you have had a recent infection, see your doctor.

6. Yearly Pap tests
The yearly Pap smear is a common part of women’s health checklists, but it doesn’t need to be. Women at average risk only need them every three years, since cervical cancer generally takes 10 to 20 years to develop. If women have also had negative tests for the human papillomavirus (HPV), which is now known to cause the cancer, they only need a Pap test along with the HPV test every five years. And women older than 65 who have had several normal Pap tests in a row can stop having them altogether. Also, if you have had a total hysterectomy for a benign condition such as uterine fibroids and the entire uterus and cervix have been removed, you do not need any further Pap test. Do note, however, that a yearly visit to an ob-gyn stays on the to-do list.

7. Bone density scan for women before age 65 and men before age 70
For the estimated 10 million people — mainly women —in the United States who have osteoporosis, bone-strengthening medications can lower the chances of breaking a bone. But many experts argue that for those ages 50 to 65 who have osteopenia — mild bone loss — testing and subsequent drug prescriptions may be a waste of time and money. Not only is the risk of fracture often quite low, medications such as Fosamax (alendronate) and Boniva (ibandronate) have been linked to throat or chest pain, difficulty swallowing, heartburn, muscle pain, bone loss in the jaw and thigh-bone fractures. And there’s scant evidence that people with osteopenia get much benefit from the drugs.
To help keep your bones strong, try walking and weight-bearing exercises,. Get enough calcium, 1000mg\day, and vitamin D, 1000IU\day, in your diet. If you smoke, quit.

8. Follow-up ultrasounds for small ovarian cysts
Many women receive repeated ultrasounds to verify that ovarian cysts have not become cancerous, but current research says that these tests aren’t necessary. For one thing, premenopausal women have harmless ovarian cysts regularly. For another, about 20 percent of postmenopausal women also develop harmless cysts.
The likelihood of these small simple cysts ever becoming cancer is exceedingly low.

9. Colonoscopy after age 75
Most people should have screening for colon cancer at 50 and then every five to 10 years after that, if the first test is normal. By age 75 — if you’ve always had normal colonoscopies — you can stop taking this test altogether. That should be good news, because a colonoscopy can cause serious complications in older people.
To protect your colon, eat plenty of fruits, vegetables and whole grains for fiber. Cut down on fatty foods, red meat and processed meats. Lose weight if you’re overweight and exercise. Sound familiar? It should, because that’s the best advice for protecting the rest of your body — and mind — as well.

10. Yearly physical
There’s little evidence that having an annual checkup can keep you healthy. Now I they tell me! Many tests that doctors regularly perform — to diagnose anemia, liver disease or urinary tract infections, for example — don’t make sense unless there’s a reason to suspect a problem.
Certainly, if you have an illness that needs treatment, you should see your physician. And do talk to your doctor about how often you need to have your blood pressure and cholesterol tested.

Bottom Line: Use good judgment about your health and your visit to the doctor. Ask the doctor if the test is really necessary and if the results will change how he\she is taking care of you. My message is that patients, including myself, need to become involved in their healthcare.
This article was inspired and modified from AARP, 10 Test to Avoid, by Elizabeth Agnvall, http://www.aarp.org/health/conditions-treatments/info-2014/choosing-wisely-medical-tests-to-avoid.3.html

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

October 4, 2013

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
http://www.nytimes.com/2008/08/05/health/research/05prostate.html?_r=0

Saw Palmetto Effect On the PSA Level

September 29, 2013

Saw palmetto is a commonly used herbal supplement used to treat men with mild symptoms of the enlarged prostate gland or BPH (benign prostatic hyperplasia). Despite years of controversy regarding efficacy, saw palmetto remains the most common herbal treatment for men with lower urinary tract symptoms.
Extracted from the fruit of the saw palmetto dwarf tree, the extract exerts effects by diminishing 5-alpha-reductase activity and binding to androgen receptors in prostatic cells. Saw palmetto reduces prostatic dihydrotestosterone by 32%. As a result of this anti-androgen effect, concerns have been raised as to whether serum PSA values should be adjusted accordingly.

In a new study published in the Journal of Urology (2013;189:486-492), researchers evaluated serum PSA values in 369 patients randomized to receive saw palmetto or placebo.
These men were part of the CAMUS (Complementary and Alternative Medicine for Urological Symptoms) trial, a double-blinded, randomized controlled study designed to determine whether saw palmetto extract reduced the American Urological Association symptom score compared with placebo at 72 weeks.
Even with triple the recommended dose of saw palmetto, serum PSA remained unaffected compared with placebo. These data can help guide clinicians using PSA for the early detection of prostate cancer in those patients taking this common herbal remedy.

Bottom Line: Many men will use the herbal supplement, saw palmetto, for the treatment of their lower urinary tract symptoms of benign enlargement of the prostate gland. There is no affect on the PSA level but middle aged men taking saw palmetto should be tested with a PSA and no adjustment need to be made in the PSA level.

How Often Do You Need To See Me?

September 1, 2012

You may wonder how the decision is made to making the next appointment for a patient. Is there a book, or now a website with guidelines, that guide physicians on when to make the patients’ next appointments? No, there is not. It is not something we learn in medical school but is something that is part of the art of medicine. Some patients really need to be seen in a few days or a few weeks such as the patient with a urinary tract infection where the urine has to be checked to be sure the infection has cleared even after the symptoms have subsided. Then there is the asymptomatic patient who is on no medications and probably needs to be seen only for a screening annual or even a biannual exam. Then there is the majority that fall somewhere in the middle of those two extremes.

What if you had diabetes, coronary disease, hypertension, high cholesterol, and sleep apnea, but no symptoms to indicate any acute problems? You’d probably see your primary doctor fairly routinely (mostly for management of diabetes) and maybe your cardiologist every six months or so.

Here’s the big question: When you’re coasting along pretty well with no actively changing symptoms but with chronic medical problems, how often do you need to see your doctors? Let’s take the example above: with those particular problems, should you see your cardiologist yearly, biannually, quarterly, monthly, or what? In the non-hypothetical world a patient’s follow-up is likely to be dictated by the doctor and set at the end of each appointment. “Okay, Mrs. X, it looks like you’re doing well. Let’s plan to see you again in 6 months.”

How does the doctor know when to see you next? There are a few ground rules to take into consideration. The pharmaceutical industry doesn’t allow us to write prescriptions with refills that extend past 12 months, and many clinics have a policy of not providing new prescriptions after the 12-month mark unless they’ve at least laid eyes on the patient (apparently to make sure the patient is indeed alive), and so most people with chronic problems will likely have to be seen at least once a year. It is amazing how many men using erectile dysfunction drugs will keep that annual appointment in order to obtain a refill of their medications! The other ground rule is common sense.

So, routine follow-up will most likely fall somewhere between “less often than weekly” and “at least once yearly or more frequently.” But within those limits, as a doctor I’m pretty much free to choose whatever I like.

I don’t know how other doctors do it, but I like to burden healthy patients with as few doctor visits as possible, so I mostly try to set my return appointments for a year. This works well for most people, but there are clearly exceptions. I see a lot of men with prostate cancer. Many of them are on medications to decrease the testosterone level and receive injections every 3-6 months. If it is possible, I try to convert these men to injections that can be given once a year. Most of the men with prostate cancer like the idea of getting a yearly injection and coming in every six months for a blood test, a PSA level. However, there are some men that want that more often and I allow them to make appointments to be seen more frequently. This, again, is where the art of medicine is used to guide how often a patient returns for an appointment.

There are patients with certain conditions like bladder cancer that should have a cystoscopy or look into their bladder with a lighted tube every 3 months. This guideline is written in all urologic textbooks and is good medicine to see these patients on a frequent basis.

I commonly ask certain patients to see me more frequently. Any patient who is on medications that is having side effects is asked to come back more frequently until I can get the dosage or the medication straightened out that provides them with the beneficial effect and with manageable side effects.

Bottom Line: How often should you be seeing your doctor? I have no clue. Between you and your doctor you’ll come up with some type of balance that works. Just understand that none of this is written in stone….i.e., a kidney stone!

This blog was inspired and modified from a blog by Dr. Eric Van de Graaf, which appeared in Patient on January 17, 2011.