BLOGGERS: MARK SCHOLZ, MD & RALPH H. BLUM

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

Tuesday, September 2, 2014

Balance, Strength and Longevity

BY MARK SCHOLZ, MD

This morning I reached a milestone.  Standing up on one leg at a time without leaning on anything, I pulled on my shoes and socks without falling over.  Ever since I hired a trainer more than a year ago my balance has been steadily improving.  But it has taken me this long to gain enough strength and balance to pull of this feat.

My goal wasn’t performing successful balancing acts when I finally threw in the towel and hired a trainer.  For years I have known about the scientific studies equating fitness with longevity.  This connection is much more significant than most people realize.  The risks of a sedentary lifestyle equate to a pack-a-day smoking habit.

Knowledge is power but only if you act on that knowledge.  For three years I bought gym memberships, purchased a spectacular exercise machine (which I am trying to sell) and treated myself to a beautiful set of matched weights (which I am also trying to sell).  I even used my equipment a few times. I made a couple of visits to the gym, but with no consistency.

What was wrong?  Most of you already know the answer.  Bottom line for me—exercise causes pain. I am a busy person. I already have enough pain in my day-to-day life.  Last thing I wanted was to spend my limited free time experiencing more pain.

But my scientifically oriented brain just can’t ignore those pesky studies showing that a sedentary life style is as dangerous as smoking.  And after all, longevity is really my life’s work. People visit me from all over the country for advice on how to reduce their risk of dying from prostate cancer. When taken in its entirety, poor fitness is probably even more dangerous than prostate cancer itself.

Hiring a trainer is what finally got me over the hump. By making myself accountable to someone, my exercise became more consistent. It turns out that it’s in my nature not to cancel training sessions lightly because it affects someone else’s livelihood and schedule.  Also, I find the presence of someone with me during exercise is a welcome distraction, making the sessions less miserable.

I say, “over the hump” because once you get started exercising, you soon notice a subjective sense of well-being, more energy, smaller waistline,  more dietary freedom and better balance.  These successes all serve to remind me that my expensive exercise habit is really worth the cost.

There is a lot more to be said in favor of fitness.  The intimate connection between balance and strength alone is a huge issue for my mostly elderly clientele.  Acquiring the right kind of fitness trainer—a discerning one—is also important.  The message is clear:  attaining fitness is achievable.  All you need is enough conviction about the benefits of exercise to break out your checkbook and hire a trainer.  
                     
 

Tuesday, August 26, 2014

First, find a Doctor You Like . . .

BY RALPH BLUM

A urologist I consulted in Hawaii, a man with a big reputation, told me to go home and settle my affairs, because I was going to die. That was 16 years ago.

When your are visiting a doctor, his reputation shouldn’t matter.  Even if he’s a great urologist or a world class prostate oncologist, If he makes you uncomfortable, dump him!  Never mind why.  This is your life. Find yourself another doctor.

Nor is this simply a matter of learning to be comfortable with personality differences. There is also a purely practical side to this— studies show that personality influences treatment selection.  “The physician a patient sees can influence their treatment fate,” according Dr. Karen Hoffman, lead author of a recent study from the University of Texas MD Anderson Cancer Center in Houston. “Physicians play an important role in whether or not men with low-risk prostate cancer are managed with observation or treatment.”

According to a new study, whether a man’s low-risk prostate cancer gets treated with surveillance, surgery or another form of radical treatment, may have more to do with his doctor than that man’s health status.   For example, the study found that urologists who have been practicing for more years or had more patients with advanced disease were less likely to use a wait-and-see approach to manage low-risk prostate cancer.

The issue of how physicians steer patients toward one treatment or away from another has become a major national health issue since prostate cancer is so common, occurring in over 200,000 men annually.  Dr. Hoffman and her colleagues write in JAMA Internal Medicine that most common type of prostate cancer, the low-risk variety, is not likely to affect how long men live even without treatment and  radical treatment  can lead to complications like rectal bleeding, impotence and problems with bladder control.

Good medicine dictates that the treatment a patient receives is supposed to be dependent on factors such as their age, health status and the stage of their disease.  Dr. Hoffman’s study euphemistically described as “doctor characteristics” as the main force driving treatment decisions. The study analyzed data from 12,068 men ages 66 years and older who were diagnosed with low-risk prostate cancer by 2,145 urologists between 2006 and 2009.

Only about a fifth of the men had their prostate cancer managed with active surveillance. The rest received up-front treatment, such as surgery or radiation.

The proportion of patients that each doctor put on active surveillance varied from less than five percent to about 64 percent.

The researchers found that doctor characteristics were twice as important as patient characteristics, such as age and other conditions, in predicting whether a patient would receive active surveillance or up-front treatment. “The rate of treatment of older men with low-risk disease is well documented to be extremely high,” said Dr. H. Ballentine Carter, professor of urology and oncology at Johns Hopkins Medicine in Baltimore “I think we need to do a better job of educating older individuals with low-risk disease.”

According to Ballantine, we are asking the wrong questions. The question should not be which treatment men need but whether they need any treatment at all.

One option for reducing potentially unnecessary treatment is to make public the track records of doctors who consistently advise radical treatment so primary care doctors would know that information before they referred their patients.

Dr. Hoffman pointed out that doctors would also want to base their decision on other measures, such as potential complications after treatment, age, and follow-up care, because active surveillance is not always the best treatment option.

Bottom line, patients need to feel good about their physician. And equally important, they must become more proactive regarding the big question: To treat or not to treat?
 



Tuesday, August 19, 2014

A Closer Look into the Book

MARK SCHOLZ, MD, prostate expert and medical oncologist and Ralph Blum, living with prostate cancer for over 20 years, co-authored "Invasion of the Prostate Snatchers:  Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency."  Written for newly diagnosed men - do research before you take the next step, rather than rushing forward.  They present a closer look into the book with these three videos CLICK HERE

KNOW YOUR OPTIONS

KNOW YOUR OPTIONS





RALPH'S JOURNEY

RALPH'S JOURNEY


DOCTOR MEETS PATIENT


Tuesday, August 12, 2014

The Unending PSA Controversy

BY MARK SCHOLZ, MD

The controversy about PSA has been reignited by new data from Lancet and recently reported in the NY Times.  Even though PSA screening reduces mortality from the aggressive type of prostate cancer, the Lancet article again confirms that far too many men routinely receive unnecessary radical treatment for a low grade type of prostate cancer that is essentially harmless, an entity that should never have been called cancer in the first place.

Grade 6 “cancers” are harmless. However, it’s hardly surprising that men (and doctors) push for immediate treatment anyway.  No amount of reasoning seems to ease the instinctual fears generated by this venomous word.  Despite warnings about impotence and incontinence—and reassurance that low-grade prostate cancer can be safely monitored— 85% of these low-risk men undergo radical treatment anyway.

Unfortunately, outrage against the genuine harms of overtreatment is routinely directed at PSA when the real culprit is the 12-core random prostate biopsy. I have previously weighed in on this matter in various blogs and videos, but the prostate cancer intelligentsia continues to be totally clueless, routinely blaming PSA rather than the ridiculous policy of randomly jabbing needles into the rectums of a million men annually.

Random biopsy could perhaps be justified if prostate scans were unreliable. In fact prostate imaging does often miss small, low-grade cancers; the very ones we now know are harmless. But for high-grade disease, color Doppler ultrasound and multiparametric, three-tesla MRI, are very accurate. Evaluating an abnormal PSA with an imaging study rather than a biopsy greatly reduces the chance of diagnosing grade 6 disease, the type that so commonly leads to unwarranted treatment.

Low grade cancers are incredibly common. However, higher-grade cancers also occur.  When imaging detects a high grade lesion, a targeted biopsy (a limited number of cores aimed directly at the lesion) should be performed. Lesions that are biopsy-negative or show low-grade cancer, can be monitored without treatment.  If high-grade cancer is confirmed, further staging followed by treatment counseling is needed.

Trained doctors using state-of-the-art technology read the scans and summarize their overall impression which falls into one of three categories:

1.        No evidence for high grade disease, no need for biopsy

2.        A suspicious lesion is detected, a targeted biopsy is necessary

3.        An ambiguous area is detected. Either a targeted biopsy can be considered or alternatively, ongoing monitoring with another scan in 6-12 months can be considered
Imaging “sees” all sorts of things besides cancer, including scar tissue, areas of active prostatitis, and nodular areas from BPH. Lesions of greater concern are located in the peripheral zone, over a centimeter in size, show bulging of the prostate capsule or are associated with increased blood flow or diffusion. An ambiguous lesion should be targeted for biopsy if it enlarges over time during observation on subsequent scanning. Expert judgment that takes each individual’s characteristics into account comes into play during a discussion between the patient and doctor about whether or not a targeted biopsy is indicated.

Color Doppler ultrasound and multiparametric MRI are complementary. In our experience, the imaging findings between these two modalities match 80% of the time. However, in a minority of cases, one imaging modality illuminates a specific lesion more clearly. Therefore, with ambiguous lesions using one modality, we usually consider additional imaging with the other modality before recommending targeted biopsy.

One would think that new advances in imaging would lead to an immediate revolution in prostate cancer management. Unfortunately many doctors are either unaware of what’s available or unacquainted with the full capabilities of the latest technology.  Finally, even well informed doctors may be reluctant to embrace imaging when they are well paid to do random biopsies.

Random biopsy continues to fly unscathed under the radar while people mistakenly blame PSA for the great misfortune of having thousands of men undergo unnecessary surgery or radiation every year. Forgoing PSA screening altogether is both foolish and dangerous. State-of-the-art prostate imaging, rather than random biopsy, should be the first step in evaluating men with elevated PSA levels.