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.   

Detoxing for Jocks

BY RALPH BLUM

Recently my friend Michael Crocker—who is 59, a serious athlete (He calls himself “an over-the-hill jock”) and, because of his family history, at risk for prostate cancer—decided that he was not paying half enough attention to the  his diet. He was exercising and getting regular PSA evaluations, but he was eating as he always had, gaining weight and feeling that something in his diet was causing him bloating  and discomfort. He decided he might be having an inflammation reaction from foods that, while not allergy based, created a food intolerance that might be irritating his gut, leaving him depressed—and adding undesirable calories/weight. He put himself on what the profession calls “a food restriction diet.”

Michael made a list of what he called possible “food triggers” and going one week at a time, began eliminating them from his diet—and watching for improvement like decline in acid reflux, better sleep, more energy.

Here is Michael’s list of foods removed from his detoxing diet. He began by subtracting soy, then moved on to wheat and dairy and shellfish, He severely limited his sugar intake, cut out artificial sweeteners entirely, allowing himself honey in small amounts.

After about eight weeks, Michael told me, “I’m eating lean and clean, and probably eating more vegetables and fruit than I ever have before in my life.”

He started reading labels, something he had never done before. (“Jocks don’t read labels. Or at least they didn’t use to.”) He discovered that the FDA had called for labeling of “food allergens” in any packaged food (most of his items) and that even if items like soy were not specifically branded, they must be labeled somewhere on the package.

By the end of three months, Michael was eating limited amounts of lean meats, concentrating more on vegetables and fruits, and adding a side order of brown rice or sweet potato when he craved carbs. He rarely felt hungry on this diet. He dealt with his craving for snacks by carrying a bag of “Trail Mix” in his briefcase.

Here is a menu he found from Dr. Amy Shah on “RiseEarth”. As Dr. Shah writes in mindbodygreen

 A typical day may look like this:

 •    When you wake up: 1 glass green juice

•    Breakfast: Chocolate Cherry (Green) Smoothie: spinach, raw cacao, frozen organic cherries, chia seeds, coconut milk

•    Snack: Herbal tea

•    Lunch: Large salad with avocado, olive oil, balsamic dressing, and tomato soup

•    Dinner: 3 to 5 Black bean burgers (no bun) with guacamole, and salsa. (Optional: sweet potatoes, veggies, and kale chips)

 

•    Dessert: 1 serving of dark chocolate (my favorite is Green and Black's 85% dark)

Michael found that he was never hungry on this type of diet, and that while he wasn’t sure exactly which of “the usual culprits” had been causing his discomfort, he was happy to live with the results (including significant weight loss) of what he calls “The Aging Jock’s Anti-Inflammatory Detox Diet.” Aka AJAIDD.

Another Milestone at Prostate Oncology, Father Joe Gets his First Apartment

BY MARK SCHOLZ, MD

Father Joe Johnson has been with Prostate OncologySpecialists since its inception. Twenty years ago, after he retired from parish work, he started pursuing his lifelong interest in medicine and computers by volunteering to do internet searches to help find new treatments for our cancer patients. Doing an internet search does not sound like a big deal today, but back in the early 1990s there was no Internet Explorer (or Netscape Navigator for that matter). Getting online required substantial computer expertise and information could only be accessed through medical libraries by payment of an annual licensing fee. Father Joe was well equipped for his radical career change out of parish work. He had previously spent a number of years as a chemistry teacher at Loyola University.

A few years later, when searching the internet became a more straight-forward proposition, Father Joe asked if he could help out in some other capacity. Our practice had a large database of early-stage prostate cancer patients who were treated with hormone therapy, but we lacked the statistical skills to analyze the results. I knew of Father Joe’s lifelong interest in mathematics, and wondered if he would consider tackling medical statistics on our behalf.

For those of you who don’t know, qualified statisticians are rarer than diamonds and far more expensive and difficult to come by. To make a very long story brief, Father Joe subsequently mastered medical statistics and has coauthored all the scientific publications at Prostate Oncology.

Throughout all the years of unsung service volunteering in our office—which as you probably know, focuses exclusively on the treatment of prostate cancer—Father Joe has been a constant and immovable rock of steadfast optimism and hope, visiting with patients and keeping them company while the doctors and nurses rush around trying to stay on schedule. Sure, after entering an exam room and introducing himself as a Catholic Priest he has to good-naturedly endure innumerable bad jokes about his being there to give last rites. But almost invariably people quickly warm up to his friendly presence. I strongly suspect that some of our long-term patients are only willing to suffer the terrible Marina del Rey traffic because of the pleasure of visiting with Father Joe.

Perhaps it’s reasonable to expect patients to put up with the terrible traffic since they only have to endure it on a periodic basis. But what about me? Back when I lived in Long Beach I used to suffer the traffic daily. Being a problem solver by nature, I began considering the purchase of a limousine. My plan was to black out all the passenger windows and don a cap every morning so that I could pretend I was chauffeuring a passenger and drive in the diamond lane. However, it was Father Joe who rescued me from my law-breaking soul.

One evening, after a long day at the office while bemoaning my own tiresome commute home, I discovered that Father Joe was on the lookout for a new place to live. Once our mutual need was discovered it led to a quick solution. Father Joe had lived in trailers off and on throughout his life. And my home in Long Beach had a huge, unused backyard easily accessible through an alley behind the property. After a quick search of the classified ads, we made a phone call. That same evening we purchased Father Joe’s new home and had it delivered to my back yard. For the next five years Father Joe’s calm and loving presence helped me fight the good fight on the 405 freeway morning and evening.

The privilege of taking the diamond lane was definitely a huge improvement. But in 2003 I got the opportunity to purchase a home ten minutes from the office. The problem was that the backyard of the new house was a hillside, with no place for a trailer. What about Father Joe? My initial calls around the Marina were very discouraging: all I was encountered were ten-year wait lists. But the problem was solved when we found out that a relative of one of our patients owned the marina across the street from the office. Father Joe has been living happily in a boat ever since. Clearly he has friends in high places.

Father Joe’s odyssey of volunteering at Prostate Oncology began twenty years ago when he was a young man. But now at age 82, what the heck is he doing living on a boat? Thank God he has not slipped on the wet dock or fallen into the water off his rocking boat. Last night I showed him a new apartment located a mere three-minute walk from the office but he ended up asking me to take him back to sleep on his beloved boat. After a lifetime spent in the small spaces of boat and trailers, to Father Joe, the one-bedroom apartment is gargantuan. I’ll take another run at getting him to stay at the apartment tonight. If that doesn’t succeed I may have to sink the boat.

Active Surveillance: Knowing the Players, Betting the Odds

BY RALPH BLUM

Prostate cancer screening has led to the diagnosis and treatment of many cancers that would not have become life threatening during a man’s lifetime. Since Mark and I published our book, Invasion of the Prostate Snatchers, stressing the over-treatment of prostate cancer, the ascent of Active Surveillance has become the most game-changing factor in the management of this disease. And yet with the popularity of robotic surgery both doctors and patients are still opting for cutting out prostate with low-grade cancer unnecessarily.

Johns Hopkins was way ahead of the curve with their Active Surveillance program. In 2011, Hopkins published the results of a study involving 769 patients with low-risk prostate cancer who had been deemed eligible for the program. After seven years, only about 50 percent of the men had been treated with surgery or radiation. This meant some 385 men got a pass on one or another of life’s more risky and unpleasant procedures. Furthermore, it must be noted that not a single patient enrolled in the Hopkins’ Active Surveillance program died of prostate cancer.

The best prostate surgeons operate on an extremely small percentage of men over the age of 70, even though they meet the criteria for low risk disease. In fact, Hopkins only intervenes surgically in about 1 percent of those men. On the other hand, nationally, more like 80 percent are undergoing surgery or radiation. More than 90 percent of men over 65 with low to intermediate risk disease undergo treatment even though it is unlikely to extend their lifespan.

Active Surveillance reduces this radical over-treatment of low-risk, indolent cancers while allowing for curative intervention if and when the cancer progresses. Yet despite the obvious virtues of Active Surveillance, the dominant view in prostate care is that everyone who gets diagnosed gets treated in a one-size-fits-all approach regardless of their age, or the grade and stage of their cancer. Which means prostates are continuing to come out at a record pace, even though there is no benefit from the procedure. Senior urologists at top academic medical centers blame a host of reasons, not the least being the pressures on for-profit private hospitals to boost the volume of procedures in order to maintain their annual profit margins. Unfortunately, there are always financial issues involved.

While evidence is mounting that for men with low-risk disease Active Surveillance is both sensible and safe, the challenge is to further refine the protocols for separating out low-risk men from the men facing uncommonly aggressive tumors. In this regard there are some new genetic tests called Prolaris and Oncotype that help detect prostate cancer’s bad actors.

Meanwhile, if your prostate cancer has been diagnosed as low-risk (which has been defined as a Gleason Grade less than 7, a PSA less than 10), and your doctor is recommending immediate radical treatment, my advice to you is to get a second opinion from a doctor who has experience in treating patients with an Active Surveillance protocol. And if the time comes when you do trade Active Surveillance for surgery, never—repeat never—hesitate to ask the surgeon you are considering employing how many radical prostaectomies he performed this year. And last year. And the year before. I have been astonished to learn that hundreds of well-regarded urologists have performed fewer than ten a year. Last time I heard, between 150 and 200 procedures qualified you as “expert.” At that pace, you’d need to be a medically trained vampire to qualify. As for robotic surgery, it makes no great difference: I still want you closing in on 200 procedures, of whatever kind, before you get access to the prostate of any of my friends!