The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, November 18, 2014

Remember: In BPH, the “B” stands for “Benign”


The prostate gland is the only organ in our body that keeps growing as we get older; all our other organs shrink and atrophy over time. A healthy prostate gland weighs around half an ounce (15 grams) in young men, and an ounce (30 grams) or more in men who are 50 or older. However, the prostate can weigh over 100 grams, in some cases causing problems with urination.

Although an enlarged prostate doesn’t inevitably lead to problems, one-third of all men older than 60 have benign prostatic hyperplasia (BPH) that causes urinary symptoms. The most common urinary symptoms are:
— Frequent urination.             
— A slow, weak stream of urine—there may be a lot of stopping and starting.
— A feeling of urgency when you feel like voiding.
— Painful, almost total blockage (this requires immediate medical treatment).

If you are having any of these urinary symptoms, in addition to a urine test to rule out a bladder infection, you will need an ultrasound scan to measure the size of your prostate gland, and to determine the nature and seriousness of the problem.

In most cases BPH can be treated with a category of medications, known as alpha blockers, that relax the prostate and make urinating easier. The best known of these is Flomax (generic name: tamsulosin). Another standard treatment is Proscar (generic name: finasteride) that works to shrink the size of the gland and, therefore, reverse the problem of slow urination from prostate enlargement.

However, if your symptoms are severe and/or multiple, you may require treatments using microwave, laser or electrical energy. Or if total blockage occurs, your urologist will perform transurethral resection of the prostate (TURP), a surgical procedure that removes the prostate tissue that is blocking the flow of urine.  This procedure is sometimes referred to as a “rotor-rooter job.”

BPH is the most common reason for urinary problems in older men. But equally important is the fact that an enlarged prostate causes a rise in PSA. The reason for this elevation is because the level of PSA measured in the blood is not only proportionate to the number of cancer cells in the prostate gland, but also to the size of the gland. If, therefore, the PSA level is appropriate for the size of the prostate, and if ultrasound imaging fails to reveal any sign of cancer, chances are the PSA elevation originates from BPH. In which case, active surveillance with regular PSA testing and occasional prostate imaging is, without a doubt, preferable to biopsy.
But the overwhelming concern of most doctors is that they might miss cancer in their patients. That concern, plus our own fear of the disease, far too often makes us jump to an immediate, unnecessary biopsy. And here’s a fact to tape to your shaving mirror:
--More than half the prostate biopsies performed annually
in the U.S. are done for evaluation of an elevated PSA
caused by Benign Prostatic Hyperplasia.
Isn’t it time we got smarter and started acting out of knowledge, instead of out of panic? And to remember what the “Benign” in BPH stands for?
VIDEO: Learn more about High PSA, Multiparametric MRI and random biopsies

Tuesday, November 11, 2014

Aspirin Lowers Prostate Cancer Mortality Rates


If a man wants to tilt his odds in favor of a longer life, he wears a seat belt, eats a good diet, gets an annual medical checkup, exercises and gets married. Yes you heard me right, he gets married.  The November 2013 issue of the Journal of Clinical Oncology reports that the risk of dying from prostate cancer was 25% lower in married compared to single men.

Yet one intervention that also has merit and that often gets overlooked is the lowly aspirin pill. Aspirin is well-established as a beneficial agent for reducing cardiac risk.  It cuts the risk of heart attacks by about 30%, a rate of reduction similar to common statin medications like Lipitor and Crestor.  A risk reduction of this degree is notable considering that heart disease is the most common cause of death in men, especially in men with prostate cancer since most of them are over age 50.

I bring the issue of aspirin to light in this blog because I want to emphasize that there are further benefits of aspirin beyond the cardiac benefits. Specifically I want to cite another article published in the Journal of Clinical Oncology in October 2012, which reports that aspirin reduces prostate cancer mortality rates. Let me paraphrase the main take home message from the article: The difference in prostate cancer specific mortality between the men with prostate cancer on aspirin compared to the men with prostate not taking aspirin was most prominent in patients with high-risk disease.  The ten year prostate cancer specific mortality was only 4% in the men taking aspirin compared to 19% in the men who were not.  For men in the intermediate-risk group mortality was reduced from 6% down to 3% by taking aspirin.

So, in addition to the known cardiac benefits, aspirin also has a potent anticancer benefit.  Incidentally, other studies have shown that aspirin has an anticancer benefit for other types of cancer besides prostate cancer.

Aspirin is not totally risk free.  For example, one out of 200 can get a bleeding stomach ulcer.  People taking aspirin who develop black stools or heart burn should stop and get further medical evaluation. Despite these risks, aspirin can clearly be beneficial in a large number of people.  Just because it is cheap and readily accessible don’t be fooled into discounting its undeniable value.

Tuesday, November 4, 2014

Finding a Skilled Specialist


Your number one priority when you have an elevated PSA and prostate cancer is suspected, is to take the time to find the very best urologist in your area. What you need now is an experienced urologist who specializes in treating prostate cancer, a urologist who is up on all the latest medical knowledge and surgical techniques, and who will thoroughly discuss all viable treatment options with you in an even-handed manner.

Your options might include nerve-sparing prostatectomy, radiation (IMRT and seed implants), cryosurgery, proton beam therapy, hormone therapy, and Active Surveillance. All prostate cancer treatments have their risks and benefits, and sometimes your best decision is no immediate treatment. I strongly suggest that you take the time to do some Internet research so that when you see the urologist you have some knowledge of the various treatments and their side effects, and know what questions to ask.

Before making any treatment decision you should also talk with a medical oncologist.  Urologists are surgeons, so if the cancer is contained within the gland, it’s not surprising that their treatment of choice would be surgery. But if you have done your homework, you will know that a prostatectomy is a complex procedure that can leave you with considerable collateral damage. Similarly, radiation therapists will likely recommend one of the targeted radiation options. However, a medical oncologist has no vested interest in either approach and is familiar with all the treatment options, so he is uniquely qualified to help you decide which treatment to select.

Your primary care doctor usually knows the names of the best local urologists and oncologists in your area. But you may want to go beyond your local area to find a specialist, in which case you can network--ask your friends if they know of any good doctors for treating prostate cancer. Search prostate cancer Web sites. Ask any doctors you have ever consulted who they would see if they had the disease. And most states have prostate cancer support groups that provide excellent advice.

Before making a final treatment decision, it is critically important to get a second opinion, preferably from a highly trained urologist, medical oncologist or radiation oncologist at one of the major cancer centers. Second opinion consultations are standard procedure; your doctor makes such referrals all the time, and a second opinion is reimbursed by most insurance programs. One other thing, be sure to take a complete transcript of your medical records with you.

Above all, don’t rush to make any pivotal decision that could influence the rest of your life while you are still in shock from the diagnosis. You have plenty of time to make sure you are selecting an experienced doctor, and one with whom you feel comfortable, and who gives you confidence.

Tuesday, October 28, 2014

Raising Awareness about MRI Imaging of the Prostate


Prostate cancer screening presents a unique challenge.  Prostate cancer is a very common, but only a minority of cases are deadly.  This creates a serious problem.  It’s good to detect high-grade disease because early treatment reduces mortality.  But PSA screening detects a lot of men with low-grade disease and these men are harmed. Why? Well-intentioned but over-enthusiastic doctors recommend treatment even though it’s truly medically unnecessary. 

Why We Over Diagnose
So what can be done?  Physician propensity for overtreatment will only change slowly.  The shortest pathway out of this dilemma is to stop diagnosing so much low-grade disease.  The crux of the problem is the random needle biopsy, a “blind” procedure that is widely considered to be the necessary first step for evaluating elevated PSA.  A million men undergo biopsy annually; 250,000 men are diagnosed; around a 100,000 have low-grade disease the can be safely monitored with “active surveillance.”

The Next Evolutionary Step
Three-Tesla multiparametric MRI (MP-MRI) scans developed by Siemens, Philips and GE can reliably detect high-grade disease without over diagnosing low-grade disease; these scanners accurately differentiate high-grade from low-grade tumors.  The availability of these new scanners makes random biopsy as currently utilized by most urologists archaic. Random biopsy involves inserting 12 needles into the rectum.  Beyond its propensity for over-diagnosis, 3% of men are hospitalized with serious infections.  Also, it is relatively inaccurate, failing to detect high grade disease over 15% of the time.

New Technology Growing Pains
Most internists and urologists are still unaware of these important technological advances.  Even those who are aware are still learning how to translate these new imaging reports into practical recommendations for their patients. Also, there is the challenge of maintaining quality control in this rapidly expanding world.  Despite these barriers the advantages of using imaging as a first step can’t be ignored.  PCRI has posted a list of centers that perform this type of imaging.  While we have some familiarity with these centers, for liability reasons we are unable to offer any official certification of their quality and accuracy.  On the other hand, new as this technology is, we feel it would be a disservice not to spread the word about its availability.