Taking Charge of Your Prostate Cancer Recovery:Fast Forward From the Old Model

RALPH BLUM

In the old model of prostate cancer care, you were rushed into radical treatment--usually surgery or radiation--often without fully understanding all your options, or the risks and side effects involved. The entire process was focused on the tumor; minimal attention was given to you as a person, and little effort was made to explore the benefits of healthy lifestyle choices, immune-enhancing treatments, reasonable delays, and emotional support.  

The emerging new model of prostate cancer care recognizes the important role you can, and should, play in your recovery. The emerging model comprehends that simply attacking the cancer is not enough. Greg Anderson, who after surviving "terminal" lung cancer founded the Cancer Recovery Foundation, has said that "Retaining a medical team without doing everything you can to help yourself is like attempting to walk on one stilt."

So what do you need to know in order to take charge of your recovery?

 There are three common misperceptions about prostate cancer:

*The assumption that the disease is as dangerous as other cancers.
*The assumption that the urologist who did your biopsy is a prostate cancer expert.
*The assumption that a quick treatment decision is necessary before the cancer spreads.

First of all, prostate cancer is unique among cancers because the mortality rate is so low. Around two hundred thousand men in the U.S. alone are diagnosed with the disease every year, and less than 3% will eventually die from it, while a majority of men who have the far more common low-risk, slow-growing prostate cancer can anticipate living a normal life span, or dying of something else.

 
Your local urologist has a busy medical practice that involves treating problems like impotence, infections, incontinence, and kidney stones. He also does biopsies. But the average urologist performs fewer than five prostate removals (prostatectomies) a year--far too few to be considered proficient. He may be a talented doctor, but he is unlikely to be a prostate cancer expert. So once you have your biopsy results, it is best to consult a prostate cancer specialist, either at a major medical center, or at a high-volume prostate cancer clinic.

As for the third misperception, it is essential, before committing to any form of treatment, that you do your own research, and are convinced the treatment you choose is the right one for you.  Do not let anyone rush you into making a bad decision. Once your category of prostate cancer is identified (Low, Intermediate, or High Risk), get on the Internet and learn about every treatment option--including no treatment whatsoever--for your type of disease.  If you are over 70, and have low-risk disease, my advice to you is to find a doctor who has experience monitoring an active surveillance protocol.

Your role in your recovery, however, doesn't end with choosing your treatment. The emphasis on lifestyle changes has been one of the most significant shifts in cancer care in the last decade. A study at UCSF showed that improving your nutrition, reducing stress and getting more exercise, can lower PSA levels.  And according to a relatively new field of health psychology called "illness representation," your beliefs and expectations also impact the outcome of your disease. So take charge of your recovery, and have faith in your choice of treatment.

Advice for the Newly Diagnosed

BY RALPH BLUM

If you are recently diagnosed, the good news is that promising new drugs and therapies, as well as new thinking about when to treat and when it is not even necessary to treat, have made a diagnosis of prostate cancer far less threatening than in the past.  Having said that, remember the old rule of the desert: "Trust in God, but tie your camel to a tree." Because the same applies with a cancer diagnosis. It's not enough to depend entirely on your medical team. Now is the time to consider what you can do to support your recovery and reduce the risk of recurrence.

First, you need to be involved in each treatment decision, making certain that you are fully informed, and that you understand the risks and side effects involved. It is all too easy to play a passive role and just go along with whatever the urologist or oncologist recommends. But you need to take charge. Research your diagnosis on the Internet. Explore all your treatment options and decide whether you do, in fact, need treatment, or if active surveillance is your best option. Get a second opinion.

Next--and I'm sure you don't want to hear this--you need to examine your lifestyle. Yes, I know you would prefer just to let your treatment get rid of the cancer.  But everyone I have talked with who has done really well in the cancer wars has made good nutrition, moderate exercise, stress management, and positive engagement in their own health and healing--key parts of their recovery program.

So where to start? Anyone overweight? A new study suggests that being overweight or obese lowers the chances of successful treatment. It is also known to increase the risk for prostate cancer, particularly for more aggressive, high-risk disease.  So experts agree that losing weight is an important first step.

A study led by UC San Francisco involving 4,600 men diagnosed with non-metastatic prostate cancer found that by substituting healthy vegetable fats--olive and canola oils, nuts, seeds and avocados--for animal fats and carbohydrates, the men lowered their risk of disease progression. Men who replaced 10 percent of their daily calories from carbohydrates with healthy vegetable fats had a 29 per cent lower risk of increasing aggressive prostate cancer.

There is no doubt that certain foods are helpful in reducing cancer growth and other foods are not. High on the "not" list is sugar, especially high fructose corn syrup, and processed meat--salami, bologna, sausage, hot dogs etc. Your shopping list for "helpful" foods should include all fish and skinless chicken breast, beans, vegetables and fruit, whole grains and breads, and non-fat dairy. It doesn't mean you can never have another slice of pizza in your life, it just means cutting out the steak and fries. Because there has never been a more important time in your life to eat well.

Here are a few other simple things you can do:

 Take Vitamin D³. Credible research links Vitamin D³ deficiency to cancer growth, predominantly breast and prostate cancer. The recommended dose is 2,000 to 4,000 IU daily.

·       Hydrate. Lack of water inhibits immune function.

·       Get eight or more hours of sleep each night.

·       Laugh a lot. Laughter is the ultimate antioxidant.

·       Listen to music.

·       Stay in the moment. Don't let past regrets and future fears contaminate the present. Remember Deepak Chopra's words: "Every cell in your body is eavesdropping on your thoughts."

 

Making Friends with Your PSA

BY RALPH BLUM

It’s a simple enough blood test. So who’s afraid of a PSA? The straight answer? Every guy who’s ever been told his PSA was elevated for his age, and that he needs to have a biopsy. Because from that point on, things can happen fast. It’s the prostate cancer version of the old Tinker-to-Evers-to-Chance double play: PSA Test to Biopsy to Surgery.

PSA is an acronym for prostate-specific antigen, a protein produced by normal prostate cells. Cancer cells, however, produce more PSA per unit volume than benign cells. Since 1986, PSA testing, although not perfect, has served as the gold standard for early diagnosis and—the area of most controversy—screening for prostate cancer.

While with the majority of younger men, early diagnosis far too often leads to unnecessary treatment and anxiety, urologists are justifiably concerned that, without PSA testing, they will miss diagnosing the less-common high-grade form. So, when in doubt, test.

So, I’m talking primarily to those of you with low-grade tumors, conditions that qualify as “chronic” and might better not even be called “cancer.” That doesn’t mean that being newly diagnosed with prostate cancer is any less of a shock. But there are things you can do to reduce the anxiety.

Bottom line, after all the millions spent and all the years of research, we still don’t have a foolproof diagnostic test for prostate cancer. So don’t panic if you get a high PSA reading. Here are some factors that can distort PSA test results in ways that don’t necessarily indicate cancer:

BPH: Benign prostatic hyperplasia, prostate enlargement caused by age or infection, can produce elevations in PSA not indicative of cancer. Check it out.

Infection: Consider the possibility of infection. When my PSA spiked unaccountably from 5 to 17, my wife, Jeanne, who practices Traditional Oriental Medicine, put me on a course of Cipro, and my PSA plummeted back to 6.5 within two weeks.

The 48 Hour Rule: Strenuous exercise, heavy lifting, sexual activity, even bicycle riding before a PSA test are all considered to negatively effect the result. So don’t do any of it before your PSA test.

Inconsistent Lab Work: Standardization between assays and labs is still lacking, making comparisons between PSA tests from different labs are unreliable. Make certain your urologist uses the same lab every time.

Then, there are those of you for whom PSA testing is a higher priority:

Family history: If you have a family history of prostate cancer, it’s advisable to begin PSA testing at 40 and repeat the test at six-month intervals.

African Americans: All African-Americans are advised to begin tests by age 40 regardless. The death rate from undiagnosed prostate cancer for African-Americans is currently twice that of Caucasian men. Partly for genetic reasons, partly from refusal to submit to the DRE, the finger-up-the-butt trick the rest of us, so to speak, take in our stride. Trust me, it’s over before you know it. 

Men Over 75: Nowadays, men over 75 are apt to be spared testing entirely. So avoid the anxiety, and have a good time? On the other hand, you might just go for the PSA test, and take the prostate cancer alert as a wake up call to get yourself a checkup.How long since your last physical, dude?

Finally, remember that the big decisions are all yours to make. So never hesitate to go for a second opinion—or a third. And if you don’t like the test results, get another PSA test done by a different lab. Or find a different urologist.

The best clinicians do not mindlessly screen all of their male patients. They decide which men should be tested based on age, symptoms, family history, expected longevity, general medical condition, physical examination findings, and—a significant factor—the patient's own request for the test. The goal of early detection remains to identify patients who have clinically significant cancers at a time when treatment is most likely to be effective.  

And here’s the really good news: 28 out of 30 men reading this blog, who do have prostate cancer, will die with it, not of it.  Regardless of its shortcomings, the PSA is still the most useful test that is widely available.

So if you’ve been avoiding it, have a PSA test done this week. And while you wait for results, instead of fretting, call the golf pro and get yourself a tee time for Saturday.

The Importance of Finding an Experienced Doctor

BY RALPH BLUM

If you don’t live in a city, finding a urologist who specializes in treating prostate cancer can be a major challenge. Usually your choice will be limited to who your primary care doctor will refer you to, generally a local urologist.  But before you take this step you need to be aware that all urologists are not created equal.

Furthermore, the average community urologist has a medical practice most of which involves treating problems like infections, impotence, incontinence and kidney stones. He may be an excellent doctor, but he does not have time to keep up with what is new in the fast moving prostate cancer field. Also, without the opportunity to treat large numbers of men with this disease, how can he be familiar with the advantages and disadvantages of all the new treatments?

So you need to develop the “I’m from Missouri and you’ve got to show me” mindset and ask the tough questions: How many cases of prostate cancer has he treated successfully? And if he recommends surgery, how many radical prostatectomies has he performed overall, and how many in the past twelve months? Does he perform nerve-sparing surgery, and if so what is his success rate with preservation of both potency and normal urinary function?

Unless you have the aggressive, high-risk form of prostate cancer my best advice is to resist your natural desire to rush into treatment that will compromise your quality of life.  Of men diagnosed over 50%have slow-growing, low-risk disease and do not need immediate treatment.  However, if you have the “just get it out” attitude, bear in mind that your community urologist is most likely not doing anywhere near enough radical prostatectomies to qualify as or stay proficient.

Despite the well-documented over-diagnosis and over-treatment of prostate cancer, during the past decade, the number of prostatectomies performed each year has more than doubled. And since all the marketing hype surrounding “the robot that can operate,” increasingly men are traveling to high volume centers that offer robotic surgery.  But remember, it’s the man behind the robot who is actually performing the surgery, and you don’t want to be on his learning curve.  Unless you find an experienced and highly skilled surgeon, a satisfactory outcome is extremely unlikely.

Many men are way too motivated to submit to radical treatment for what is typically a non-life-threatening condition. A combination of the urologist’s preference for surgery and most men’s desire for closure, leads to tens of thousands of unnecessary radical prostatectomies every year. You are about to make a pivotal decision that will affect the rest of your life. So before you make any treatment choice, you owe it to yourself to get a second opinion from a prostate cancer specialist—even if it means traveling to a city where such practitioners are available.

In Praise of Feisty Patients

RALPH BLUM

I have learned through personal experience that there is an art to being a patient. You must choose wisely when to submit and when to assert yourself, especially if you have just been diagnosed with prostate cancer.

Because prostate cancer is so common, and in most cases so slow growing, to submit  to any form of radical treatment without doing your due diligence, could be a serious mistake and hugely detrimental to your quality of life. Yet most doctors you consult will advocate some form of radical treatment. It’s what they know, what they do. And it goes against the grain for both doctors and patients alike to put off treating prostate cancer.

However,  let’s take a moment and put things in perspective. Fifty percent of older men have the disease, live with it, and die from something else—sometimes without ever knowing they had a life threatening condition. Furthermore, the life expectancy of men with recurrent prostate cancer often stretches out well past a decade. And yet the radical prostatectomy-- one of the most complex and challenging surgeries because the prostate is located in absolutely the wrong place for a simple surgical solution—is still the most widely recommended treatment option, the most often unnecessary, and the one most likely to leave you incontinent and/or impotent.

My own experience with urologists has not always been a happy one. Twenty-five years ago, a Honolulu urologist who wanted nothing but patient compliance, told me that if I did not agree to immediate surgery I would be dead in two years. His recommendation and prognosis were not only wrong, but in my opinion violated the ancient medical precept incorporated in the Hippocratic Oath: “First do no harm.” Fortunately I was not the kind of patient to be easily intimidated.

My decision to engage in watchful waiting, monitor the cancer and take the time to educate myself, has given me almost three decades of quality time with my wife that almost certainly would have been lost or diminished if I had committed to immediate surgery. The feisty, “difficult,” assertive patient, the one who challenges the doctor, is often the one who has the best outcome.

If I had it all to do over again, I would seek to change nothing.

 

Finding a Skilled Specialist

BY RALPH BLUM

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.

Raising Awareness about MRI Imaging of the Prostate

BY MARK SCHOLZ, MD

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.

CHECK OUT THIS VIDEO: SO YOUR PSA IS HIGH, NOW WHAT? http://youtu.be/6QgcfVBzFNs

First Stop on the Overtreatment Express: The Unnecessary Biopsy

RALPH BLUM

The first four words of the subtitle of our book, Invasion of the Prostate Snatchers are, “No More Unnecessary Biopsies.” At the appropriate time, a biopsy is an essential diagnostic tool. Unfortunately, however, far too many urologists still schedule an immediate biopsy if there is even a slight rise in PSA. And that has led to a multi-billion dollar industry bent on administering treatment to every kind of prostate cancer, whether it is life-threatening or not.

So what do you need to know before agreeing to submit to a biopsy? There are several possible reasons for an elevated PSA besides cancer:

1. A prostate infection, in which case a simple course of antibiotics may be all it takes to lower PSA into the normal range. Years ago my PSA went zooming up from an infection.

2. PSA rises after sexual activity, so abstinence is necessary a day or two prior to testing.

3. Recent bicycle riding activity can cause an elevated PSA.

4. An enlarged prostate—aka Benign Prostatic Hyperplasia, or BPH—usually results in an elevated PSA. More than half the biopsies in the U.S. are performed for evaluation of an elevated PSA coming from BPH.

5. A random laboratory error is always a possibility, and occurs more often than we realize.

So rather than triggering the scheduling of an immediate biopsy, an “abnormal” PSA should set a risk-assessment process in motion. The first step is to eliminate any of the above possible causes—checking for an infection, repeating the PSA to see if a lab error caused the elevation, performing an ultrasound scan to determine the size of the prostate to see how much BPH is present, and to determine whether the ratio between PSA and prostate size is in the expected range.

 

If these measures all fail to explain the elevated PSA, further testing—with an OPKO-4K blood test that is specific for high-grade cancer—should be considered before resorting to a biopsy. Other useful procedures prior to undertaking a biopsy are color Doppler ultrasound and/or multiparametric  MRI. Imaging studies provide an accurate measure of the prostate size so that the PSA “density” (PSA elevation in the context of prostate size) can be calculated.  If  the OPKO-4k,  PSA density and imaging are favorable, then surveillance with periodic PSA and  imaging, may be preferable to an immediate biopsy.

 

You have probably realized by now that I am not a fan of biopsies.They can be painful, can cause erectile dysfunction, and fail to spot cancer as much as 20% of the time, especially in men with large prostates. But the main reason I am against unnecessary biopsies is because of the unnecessary radical prostatectomies that usually follow—estimated at above 80,000 annually in the U.S. alone. Having a biopsy is like opening Pandora’s box.

 

According to Thomas Stamey, M.D., who developed the PSA blood test, prostate cancer is a disease that almost all men get if they live long enough. So the older the man, the more likely a biopsy will reveal cancer. But that doesn’t mean every man should have his prostate removed. However, only too often, that is what happens. The treatment of choice of most urologists is surgery (they are, after all, surgeons), and most men yield to the emotional appeal of “cutting it out.” This unfortunate situation is what led to Stamey’s famous quote: “When the final chapter of this disease is written, it will prove that never in the history of oncology will so many men have been so over treated for one disease.”

 

An unwarranted biopsy is the first stop on the Overtreatment Express.

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? 

Is Prostate Surgery Right for You?

RALPH BLUM

As I wrote in my last blog, once your family doctor has referred you to a local urologist and you have been diagnosed with prostate cancer, your first and most important decision is choosing a doctor with the necessary skill and experience to help you weigh all your options and determine your best course of action. This doctor may not be your community urologist.

Provided the cancer is still contained within the prostate gland, and provided there is no medical reason surgery is contraindicated, your urologist (who is a surgeon) will almost certainly recommend it. And in your emotionally vulnerable state, and with a natural desire to just get rid of the cancer, it is quite likely you will uncritically take his advice, without question or research.

After talking with your urologist you may come away with the impression that prostate cancer surgery is fairly straightforward. It is not. Anatomically, the prostate is in absolutely the wrong place for a simple surgical procedure. Located as it is within millimeters of the bladder and the rectum, there is zero tolerance for a slip of the scalpel. To make matters worse, there is prolific venous blood supply surrounding the gland, and on a bad day even the best surgeons can end up operating in a pool of blood, and with restricted ability to see clearly in order to spare the miniscule nerves (thinner than a human hair) that control erections. With such an intricate and complex procedure the high rates of impotence are hardly surprising.

So much skill is required to successfully perform a radical prostatectomy that being operated on by less than the very finest surgeons dramatically increases the chances for a poor outcome. Levels of ability vary widely from surgeon to surgeon even in prestigious university centers. In 2004, Dr. Peter Scardino, Chief of Urology at Memorial Sloan-Kettering, published a study documenting the differenced in “talent” in this unregulated field. The study evaluated the surgical skill of twenty-six urologists on staff at Sloan-Kettering and Baylor.  The indicator used to measure skill was the frequency of leaving cancer behind after the operation (the technical term is “positive surgical margin”). The study reported that the best doctor in the group left cancer behind in 10% of his cases. The positive margin rates of the other twenty-five urologists ranged from 11% to a shocking 48%.

 

Despite these disturbing statistics surgery is still the primary treatment of choice for those diagnosed with prostate cancer. Yet while a select few surgeons perform dozens, perhaps a hundred or more procedures, generally speaking, the average urologist performs fewer than half a dozen prostate operations a year. In the U.S. there are somewhere around 70,000 radical prostatectomies done annually, and there are 10,000 urologists. If you do the math it’s clear that your community urologist is probably not doing enough prostate surgeries to stay proficient.

 

So buyer beware. Before you consent to surgery be sure to ask your urologist how many nerve-sparing prostatectomies he has performed--it should be at least 50. Preferably upwards of 200. Did often he get positive surgical margins? What percentage of the men he operated on are sexually potent a year after the procedure? What percentage suffers from incontinence a year later? And if you are over 70 years old and your urologist is recommending surgery, find another urologist, or better still, a prostate oncologist.

 

I hope this short essay has helped convey the importance of not rushing into treatment.  It bears repeating: Go slowly. Do your homework. I have avoided surgery for almost 25 years. Consider the options, including—since surgery is only right for some of you—“Do nothing,” which for many men translates as “Die with prostate cancer, not from it."

I Am Not a Urologist

BY MARK SCHOLZ, MD

In February, while attending the tenth annual GU-Oncology meeting, I was surprised to see my name listed on large posters around the meeting hall (along with about 30 other physicians).  The hosts of the meeting were honoring a very small group of doctors who have attended every single American Society of Clinical Oncology Genitourinary (ASCO-GU) meeting since the meeting’s inception 10 years ago.

A Prostate Cancer World Populated by Surgeons
It’s not surprising that at a meeting of 2,500 attendees, only 30 doctors were honored. This was not a urology meeting, as is typical with most prostate cancer meetings. This meeting was hosted by the American Society of Clinical Oncology*, an association of medical oncologists. Only 30 doctors were on the list because medical oncologists who consistently attend meetings focused on prostate cancer are rare. The prostate cancer world is run by urologists, who are surgeons. Urologists have dominated prostate cancer for 100 years, dating back to when surgery was the only effective cancer treatment available.

What is a Medical Oncologist?
I tend to assume that all my patients know that I am a medical oncologist, not a urologist. However, when I speak to patients, I frequently discover that men fail to understand the difference. The following short list might be help helpful.

Medical Oncologists:  

1.    Take leadership of a medical team comprised of medical doctors from various specialties

2.    Are trained to manage all types of cancer

3.    Supervise multimodality therapy (surgery, radiation, immune, hormonal and chemotherapy)

4.    Are board certified in internal medicine as well as medical oncology

5.    By observing patient outcomes, learn through first-hand experience which surgeons and radiation doctors are the most skilled

6.    Are trained in how to administer multiple different types of medications—both for cancer treatment and for overall health needs—safely, in combination

7.    Have no innate preference for surgery over radiation, since they perform neither

Urologists:

1.    Are trained first and foremost as surgeons

2.    Are trained to care of numerous noncancerous maladies of the genitourinary tract (kidney stones, erectile dysfunction, bladder infections, prostate enlargement, vasectomies, repair of congenital anomalies, urinary leakage, etc.)

3.    Have no internal medicine training

4.    Have a rudimentary understanding of cancer treatment (outside of doing surgery)

Let’s take up the issue of leadership. In this complex modern era, good medical outcomes require a coordinated team effort that maximizes the participation of all the different medical specialties. Five specialties commonly participate in prostate cancer management: urology, radiation oncology, radiology (reading scans), pathology (reading biopsy specimens under the microscope) and medical oncology.  Obviously, any kind of team, medical or otherwise, performs best with knowledgeable and experienced leadership. With almost every other type of cancer (besides prostate cancer) medical oncologists take the lead.

Longstanding Tradition Makes Prostate Cancer the Exception to the Rule
It’s surprising to most people that university medical oncology fellowship programs (like USC, where I trained) offer no training in the management of early-stage prostate cancer. This role has been totally abdicated to the urologists. While advanced-stage prostate cancer patients do transfer their care to oncologists somewhat more frequently, this happens in only half the men with advanced disease.

Studies show that 50% of men with advanced prostate cancer who succumb to progressive disease die without ever consulting with a medical oncologist!  This practice of urologists holding onto their patient to the bitter end may have been defensible back when the effective treatment options for advanced disease were limited to Lupron, Casodex and palliative spot radiation to the bones. However, forgoing oncology consultation in this modern era of Provenge, Zytiga, Xtandi, Xofigo and Jevtana, all of which are proven to prolong survival, borders on lunacy.

Yet despite there being over two million prostate cancer survivors in the U.S., less than a one-hundred (100) medical oncologists who actually specialize in prostate cancer, and almost all of these are in academia doing clinical or laboratory research. Outside of academia less than ten (10) medical oncologists specialize in prostate cancer fulltime. Three of these are in my office in Marina del Rey. The other free-standing medical oncology clinics that specialize in prostate cancer are listed at www.goo.gl/hfFt3F

Practice Makes Perfect
Real day-to-day clinic experience treating large numbers of men with one disease—in this case prostate cancer—improves the skill level of the practicing doctors. Skillful doctors are of great value because new medicines are being approved at an ever faster pace. Familiarity with their use can only be achieved at a high-volume prostate cancer clinic. A fulltime prostate oncologist gains practical experience that takes years to appear in textbooks.

Furthermore, prior to FDA approval, new drugs can only be obtained by participating in clinical trials. But it’s dangerous to conclude that every agent under clinical investigation will provide meaningful benefit. While there is no absolute inside information, most of the prostate oncologists in the country know each other so “inside information” can be learned from a simple phone call or a chance meeting at one of the various prostate meetings that occur throughout the year.

Finally, doctors who are involved in managing large numbers of men with prostate cancer also gain experience with the relative skill levels of other physicians on the medical team; the surgeons, pathologists, radiation therapist and the radiologists. Improved patient outcome is not simply the result of picking the right treatment.  You also have to select a doctor with special talent to administer it.

Conclusion
Don’t make the common mistake that urologists and medical oncologists are inter-changeable.  Having a highly trained and skilled surgeon can be lifesaving—when surgery is truly indicated.  However, in this modern era, radical prostatectomy should be the first choice in relatively few men. And even when surgery is the preferred approach, having a surgeon as the overall leader of your team is no longer ideal.

P.S. My apologies for radically digressing from the exciting information shared at the meeting.  My frustration with a world dominated by urologists clearly got the best of me.  I’ll take up the meeting highlights in my next blog (and in even greater detail in the next issue of PCRI Insights).

* As an aside, the acronym, ASCO, in Spanish means nausea, a name some consider apropos since oncologists are the main purveyors of chemotherapy.

PSA Screening for Prostate Cancer

BY MARK SCHOLZ, MD

Most elderly men already have prostate cancer—they just don’t know they have it.  And they might be better off remaining ignorant. Newly-diagnosed men are thrown into an eight-billion-per-year medical world that extols radical treatment. Over-treatment is so out-of-control that a New England Journal of Medicine study estimates that forty-eight men are getting unnecessary surgery or radiation for each individual who truly benefits from them.

Random Biopsy, Not PSA is the Real Problem
When PSA is elevated, primary care physicians usually refer to a urologist for an immediate 12-core random prostate biopsy. One million men are biopsied annually in the United States. Few people realize that even when the PSA is normal, the biopsy will be positive 20% of the time. The problem is that a diagnosis of any prostate cancer, even the Low-Risk type, almost invariably leads to surgery or radiation.

Biopsies Are Not Benign
Over-diagnosing Low-Risk prostate cancer, and the attendant risk of over-treatment, is not the only problem caused by random biopsy. Consider the emotional devastation caused by a cancer diagnosis. Men are literally frightened to death by the discovery of prostate cancer: The first week after diagnosis, the risk of suicide and heart attacks jumps dramatically. In addition, 3% of men suffer biopsy-induced infections resulting in hospitalization. Fatal infections are estimated to occur in approximately one-thousand men undergoing random biopsy per year.

Stop PSA Screening?
Due to all these mounting negatives, the US Preventative Services Task Force now recommends that routine PSA testing cease altogether. The Task Force’s conclusion was that unnecessary treatment to over a hundred thousand men annually is too big a price to pay even though PSA screening saves lives. The Task Force fails to understand that overtreatment isn’t caused by PSA, it’s what physicians do with the information PSA provides—they automatically refer every patient for immediate random biopsy.

PSA Is Heavily Influenced by Prostate Size
Most PSA originates from the prostate gland, not from cancer. Therefore, when the cancer is relatively small, PSA is a reflection prostate gland size. In a man without cancer, PSA normally averages one-tenth of the prostate volume. For example, the average PSA for a 30cc prostate is 3; five for a 50cc prostate and 10 for a 100cc prostate with size determined by ultrasound or MRI.

Therefore, PSA can only be termed “abnormal” if it’s 50% higher than expected, based on a man’s prostate size. For example, an abnormal PSA for a 30cc prostate is 4.5, a 50cc prostate, 7.5 and a 100cc prostate, 15. Additional extraneous factors such as low-grade infections, lab variations and recent sexual activity can also cause PSA to vary.  Repeat testing helps average out these variations so the “real” PSA can be determined.

Primary Care Doctors Are the Source for Balanced Counsel
Only the primary care physicians can stop the mindless rush to random biopsy. Instead of referring for random biopsy they can send their patients with elevated PSA for prostate imaging with multiparametric MRI or Color Doppler Ultrasound. Imaging can put the PSA elevation into context by determining the prostate size. Also, in the hands of an experienced radiologist, using state-of-the-art, three-Tesla MRI, high-grade cancer can be ruled out with 95 to 98% accuracy.

If imaging detects a high-grade lesion, primary physicians can then counsel their patients about whether a targeted biopsy directed at the abnormal lesion should be performed. Alternatively they can recommend simple monitoring with a repeat imaging study six to twelve months down the road to determine if the lesion is growing. Lastly, if a targeted biopsy shows cancer, rather than being guided by a urologist, who is, after all, a surgeon, patients can obtain counsel from their primary physician, a non-surgeon who can provide unbiased assistance in selecting the best treatment.

Estimating Cancer Risk
If men are concerned about the risk of forgoing an immediate random biopsy they can estimate the percentage likelihood of harboring low-grade or high-grade disease with an online calculator by googling, “risk of biopsy-detectable prostate cancer.”

Imaging Rather than Biopsy
Prior to PSA screening men should be informed that if PSA is high, the first step should be imaging rather than random biopsy. Random biopsy can cause serious infections. It also diagnoses Low-Risk prostate cancer, a harmless condition that nevertheless, often leads to unnecessary treatment. PSA screening, while saving lives by detecting High-Risk cancer at an early stage, can also, if handled improperly, lead to unnecessary treatment with many lifelong side effects.