Sometimes Going Fishing with the Doctor Isn’t So Much Fun

BY A PATIENT OF MARK SCHOLZ, MD

When you go fishing, you can bring up all kinds of things besides fish—old rubber boots, pieces of a broken net and discarded trash. Once I caught an eel.  You never know what you will drag in when you drop your line overboard. 

The same analogy holds true for diagnostic testing in the medical world. Investigative studies can have unintended consequences. Of course the studies seem justified at the time. We presume that the doctor is being rightfully conscientious by using all the tools of modern medicine, “fishing” for the right answers.

Dr. Scholz asked me to relate the story of an extended medical fishing trip that started with my dermatologist for my annual, too-much-California-sun screening. While talking to my dermatologist, I mentioned some itching on my arms.  He gave me a few samples of lotion and referred me to my internist for further evaluation and blood testing to “make sure” the itching wasn’t a symptom of something more serious. My internist ordered some lab work (which was normal) but recommended that I have a routine chest x-ray since itching can be associated with lung cancer.  This suggestion may have occurred to him because he knew that lung cancer caused my mother’s death.  Since I hadn’t had a chest x-ray in years, I thought, “why not?”

In retrospect, the chest x-ray may have been a mistake.  Because that’s when the boat left the dock and the fishing really began in earnest.  Two days later, the chest x-ray revealed a “suspicious” spot on my lung. So, to identify what it was, a CT was ordered.  The spot was benign. “Whew!” It was only a bone artifact (the end of a rib visible due to the angle of the x-ray).  But…. the CT scan showed a suspicious spot in the liver, which shouldn’t have been there and was large enough to be of concern.  So, an MRI of the abdomen was ordered.  The MRI revealed that the liver spot was nothing but a harmless hemangioma, a collection of blood vessels that are common and mean nothing.  Another big relief. But…. guess what else the MRI found?  At the top end of the scan in my lower neck, it showed some abnormalities in my thyroid “that could not be ignored.”  So, a thyroid ultrasound was ordered.  It revealed two nodules that looked benign and would have been ignored completely if there had only been one.  But the only way to really know what types of cells the nodules consisted of was by doing a needle biopsy or an exploratory surgery. 

Yikes!  When would I get off this merry-go round?  Who could imagine that simply mentioning some itching to a dermatologist would lead me face to face with the possibility of thyroid cancer.  However, the doctor was kind enough to offer another alternative.  Because of the known, slow-growth rates of typical thyroid cancers, active surveillance and re-testing at future intervals was also an option, and the one I have selected.

So, six months later, a second thyroid ultrasound—my fifth imaging test—showed no changes from the previous test.  The fishing trip finally seems to be over.  I am back in the waiting pool anticipating next year’s medical expedition, much the same as the next round of prostate screening tests I am scheduled to undergo early in 2017.  Now, routinely surveilling my thyroid is going to be just like my prostate.  If next year’s fishing trip doesn’t run down any new tributaries and is uneventful, I expect it may even be possible to extend by a year or two the time the frequency of testing.

My medical fishing trip was not much fun.  Personally, I’d rather spend my time working, biking or walking, or doing almost anything besides waiting for the next set of results from the last odd thing that showed up unexpectedly. But life goes on and it isn’t possible to know precisely how it will end.  My recommendation—Give careful consideration to your doctor’s invitation to go fishing.  Take control over your medical destiny and ask you doctors if close surveillance is an alternative to further testing. 

Sir Spheres for Liver Metastases from Prostate Cancer

BY MARK SCHOLZ, MD

Cancer that spreads outside the prostate gland is what makes prostate cancer dangerous. Metastatic prostate cancer cells cause malfunction by impeding normal function. Some organs, like lymph nodes for example, continue to function quite nicely, even if the degree of cancer spread is extensive.  Lymph node spread, therefore, is the least dangerous form of prostate cancer metastases.  At the other end of the spectrum is the liver, which is far less tolerant.  The seriousness of bone metastases, the most common site of prostate cancer spread, lies about half way between that of node metastases and liver metastases.


The earliest stages of metastases are microscopic and therefore invisible even with the best available technology. To be detected with the best available PET scan technology, small tumors must measure more than 1/8 of an inch across. For detection with standard CT scans and MRI scans, more than a half-inch sized tumor is necessary. Since the presence of metastases is such a defining issue when describing a cancer’s character, men who are newly-diagnosed are labeled as low, intermediate or high-risk depending on their estimated likelihood of micro-metastatic disease. Liver metastases are extremely rare at the time of initial diagnosis of prostate cancer. When they occur it is usually after many years of ongoing treatment for known metastatic disease in the bone.


Prophylactic treatment with hormone therapy, chemotherapy or radiation to treat the possibility of micro-metastases is common for high-risk prostate cancer and occurs maybe half the time in intermediate-risk prostate cancer. The goal is to cure the micro-metastases at an early stage when they are most susceptible to eradication, thus preventing the future development of detectable metastases which is what makes cancer life threatening.


When talking about prostate cancer, even though this is a blog about metastases, it should always be remembered that many common types of prostate cancer never spread. These low grade “cancers” are genetically distinct and represent a totally different category of disease.  However, when discussing the type of prostate cancer that is capable of metastasis, the following factors impact how dangerous it is:

1. The site of spread.
2. The extent of spread
3. The tumor cell growth rate
4. The efficacy of available treatment

As noted above, the liver is far less tolerant to metastatic invasion than bone or lymph nodes.  In addition, because liver metastases tend to occur in men with advanced disease, tumor growth rates tend to be brisk. Also, the most commonly administered treatments, hormone therapies and chemotherapy, have often already been tried before liver metastases first develop. The advent of liver metastases, therefore, usually represents a very serious and life threatening issue.


Liver metastases may first be suspected when standard blood tests such as ALT, AST or ALP which are components of a hepatic panel blood test, register outside the normal range. Investigation into their cause often leads to doing a CT scan or MRI scan of the abdomen and pelvis to confirm the presence of disease in the liver. Alternatively, a scan may detect abnormal spots in the liver during routine periodic scanning that is being performed as regular surveillance.


Hormone therapy with Lupron, Zytiga and Xtandi, or chemotherapy with Taxotere, Jevtana and Carboplatin, is the standard approach to treatment for liver metastasis.  However, these treatments may have already been tried or may no longer be effective.  Since liver failure is tantamount to death, prostate cancer growth in the liver needs to be stopped immediately, regardless of how the disease is faring in the bones or nodes.


Much that has been learned about the treatment of liver metastases comes from reviewing common methods for managing metastatic colon cancer. The liver is the cancer’s preferred site of metastatic spread for colon cancer.  Treatments that have been employed include surgery, radiation and blockage of the blood supply to the liver by embolization of the arteries, all with variable success.  More recently, radioactive microspheres injected directly into the tumor, called SIR-Spheres, have shown notable efficacy with very tolerable side effects.


Prostate cancer and colon cancer are similar in that they are both adenocarcinomas which means they are derived from glands. Therefore, they are likely to have similar susceptibility to radiation.  As such, we have been administering SIR-Spheres to a limited number of prostate cancer patients with liver metastases.  Results have been encouraging with a notable improvement of survival compared to our historical experience treatment patients with liver metastases without SIR-Spheres.  Our preliminary results using SIR-Spheres in six patients is being presented at the 2016 Genitourinary Cancers Symposium - San Francisco in January 2016.

African-Americans and Prostate Cancer

BY RALPH BLUM

The hard fact is that the death rate from undiagnosed prostate cancer for African-Americans is currently more than twice that for Caucasian men. Although scientists do not yet fully understand why this is so, it is widely believed that genetic differences, lifestyle, reluctance to undergo digital-rectal testing, and nutritional habits all play a role in these statistics. Which is why all African-Americans are urged to begin tests at an earlier age (40) regardless of their health history.

While African-American men are already at an increased risk for prostate cancer, that risk goes up even further if there is a family history of the disease. African-American men, with an immediate family member who had prostate cancer before age 65, have a one-in-three chance of developing the disease. With two family members involved, that risk rises to over 80%. This is why prostate cancer screening at a younger age is vital because by the time that symptoms appear, the cancer is more likely to be at an advanced stage.

The differences in prostate cancer diagnosis and treatment seem to account for a significant portion of the gap in death rates between blacks and whites.  First, black men are less likely than whites to have adequate insurance. Uninsured men have lower rates of screening and are less likely to see a health care professional. These men are more likely to be diagnosed with advanced disease –cancer that has spread outside of the prostate gland. It is worth noting that studies of blacks and whites in the military, where men have equal access to health care services, have shown that this equal access eliminates of most of the death rate gap.

So what can African-American men and their health care professionals do right now?  The advice is the same for black men as for all other men. Focus on early diagnosis through PSA screening.  The controversies about PSA screening are mostly related to over diagnosis of low-grade disease.  Many of these low-grade cancers don’t even need to be treated. They can be safely watched. And that fear can largely be address by evaluating an abnormal PSA finding with a MRI scan rather than a 12-core random biopsy.  Given the extremely high rates of prostate cancer in African-American men, getting a PSA test represents a simple but potentially life-saving act.

The TEAL Shade of Blue

BY MARK SCHOLZ, MD

People assume that the differences in the way prostate cancer behaves—one man develops symptoms and another doesn’t—is because they are seeing different stages of the same illness.  What’s overlooked, often with disastrous consequences, is that these differences are also due to the fact that distinct varieties of prostate cancer exist.

Receiving optimal therapy depends on matching an appropriate treatment with both the correct stage and the correct type of prostate cancer.  Since blue is the color for prostate cancer, as pink is the color for breast cancer, the PCRI has subdivided prostate cancer into five major Shades of Blue. These shades incorporate both the stage and the type of disease. The five shades are SKY, TEAL, AZURE, INDIGO and ROYAL.

The first three shades, SKY, TEAL and AZURE, represent men who have had no previous surgery or radiation. TEAL is what medical professionals call “Intermediate-Risk.” Men in the TEAL shade have identical characteristics to SKY—PSA under 10, Gleason under 7 and a small nodule (or no nodule) on digital rectal examination. However, in addition, men in TEAL have one of the following: PSA between 10 and 20, or, Gleason of 7, or digital rectal exam with a “biggish” nodule confined to one side of the gland.

Since men in TEAL have a small but real chance of cancer spread, staging scans of the bone and body are needed.  In addition, a multiparametric MRI or a Color Doppler Ultrasound should be done to check for spread around the gland just outside the capsule. If extra-capsular disease is seen, the shade changes from TEAL to AZURE.

Treatment for TEAL
The list of treatment options for TEAL is long.  While occasionally men are candidates for active surveillance— particularly those who are older—one of the following treatments is usually administered: Robotic surgery, open surgery, intensity modulated radiation, temporary high-dose seed radiation, permanent seed radiation, a combination of seed radiation and IMRT, proton therapy, Cyberknife, focal therapy or testosterone inactivating pharmaceuticals (TIP).  Sometimes a short course of TIP is combined with radiation.

Focal therapy “focuses” treatment on the cancer itself rather than the whole gland.  Typical tools used for focal therapy are cryotherapy, HIFU or laser. In general, skillfully administered focal therapy is thought to be associated with a lower risk for side effects and only slightly higher risk of future cancer relapse. However, focal therapy is very new and there are relatively few studies accurately describing long-term results.

Another option is to use TIP. TIP causes the cancer to shrivel up.  Typically TIP is continued for six to twelve months after which men are placed on active surveillance.

One general principle is that treatment success depends just as much on the skill of the administering doctor as it does on the type of treatment selected.

The second general principle is that cure rates with most of the different treatments are so close that for comparison purposes, they should be considered identical. Of course, the truth of this principle is predicated on the assumption that all treatments are administered by equally skilled experts.

Side Effects of Treatment
The prostate gland is so close to other critical organs it becomes very difficult to target the gland without damaging surrounding structures. The most common side effects, therefore, are persistent difficulties with sexual, urinary or rectal function.  For example, after radiation in an average 65-year-old, about 75% of men will recover back to their normal pretreatment level of urinary function. About 50% will recover back to their normal pretreatment level of sexual function. After surgery, about 50% of men have urinary function that is restored but only 20% describe their sexual function as recovering back to baseline.

Predictions about the incidence of side effects after focal treatment are less than certain because this technology is so new. Overall, assuming that the treating physicians are skillful, one would expect somewhat better potency rates and somewhat lower cure rates compared to standard surgery or radiation.

Comparing TIP with others options is even more difficult.  Cure rates are certainly much lower. However, the good news is that permanent side effects are rare.  The three most troublesome side effects during therapy are low libido, weight gain and fatigue. Weight gain and fatigue are partially counteracted with diligent diet and exercise. Low libido only resolves after TIP is stopped. Other common side effects such as hot flashes, calcium loss from the bones, mood swings, breast growth and erectile dysfunction can be prevented with medication.

Final Thoughts
Men in the TEAL Shade of Blue, compared to men in the other shades, face the biggest challenge—making a therapeutic choice.  First, there are so many options. Second, none of the options are attractive.  The “best” choice is only relatively better than the others; it’s never something you want to do. Making the best choice for yourself requires good comparison shopping skills, and that requires extensive homework. There are no shortcuts. Third, the biggest differences between the options are not related to the cure rates, it’s the concern about permanent side effects that needs the most attention.

Therefore, my recommendation for selecting treatment is to create a list of all the reasonable choices and study them closely, especially in term of the potential long-term side effects.  The “worst” choices should be eliminated one by one. The last option left on the list will probably be the best treatment for you. 

Dying for a Biopsy?

MARK SCHOLZ, MD

Screening for prostate cancer is big business. The PSA blood test, first implemented in the late 1980s, resulted in a doubling in the number of new cases, from 100,000 a year to more than 200,000 annually. The cost of simply diagnosing prostate cancer—after adding up doctor, lab and pathology charges—easily surpasses a billion dollars annually.

Cancer is diagnosed by a specially-trained doctor, a pathologist, who examines the prostate tissue under a microscope. Tissue is extracted by needle biopsy, a procedure that is performed in a doctor’s office. The patient lies on his side and an ultrasound probe is inserted into the rectum. Then after Novocain is injected, 12 to 14 tissue samples are removed using a spring-loaded needle gun that is fired in a grid pattern over the surface of the prostate . The tissue samples are then transported to the pathologist who determines whether or not cancer is present.

Over a million men undergo a prostate biopsy each year. Immediate biopsy at the first sign of PSA elevation has been the standard approach for more than 30 years. However, this policy needs to be reconsidered. Last year the US Preventative Services Task Force reconfirmed their strong warning against PSA screening, pointing out that it leads directly to an egregious degree of overtreatment in men with microscopic amounts of harmless low-grade prostate cancer.  The problem is that surgery and radiation induce shockingly high rates of permanent sexual dysfunction and loss of urinary control. These are distressingly serious problems when considering that treatment is frequently unnecessary in the first place.

Until recently, the needle biopsy procedure itself was perceived as being reasonably safe. However, two just-released studies indicate that it is nowhere near as innocuous as most physicians had assumed.  For example, at the American Urology Association meeting in May, doctors from Memorial Sloan Kettering reported that infectious complications requiring hospitalization occur 2.8% of the time.* In a separate study at the American Society of Clinical Oncology meeting, Dr. Boniol from the International Prevention Research Institute reported that 1.3 deaths occurred for every 1,000 men who undergo biopsy. To put this latter finding in perspective, Dr. Boniol commented, “This prostatic biopsy mortality would occur earlier than any benefit from a screening program and could reverse any potential gain from screening…”

Fortunately, there is an alternative to immediate biopsy.  MRI scanners can guide a biopsy needle directly to the area of the prostate gland where the disease is located, thus allowing a reduction in the number needle biopsies by 90%.  While there are drawbacks to this new technology—it requires special training and the equipment is expensive—the risk of serious infections should be much lower.

Change is often resisted by the status quo, especially when it involves a major shift in reimbursement patterns.  Doctors who do random prostate needle biopsies will likely view these technological advancements with suspicion. Even so, the 30-year old methodology of puncturing the prostate with multiple random needle sticks is overdue for replacement. Noninvasive MRI imaging technology to detect prostate cancer is a far more sensible way to evaluate men with rising PSA levels. 

*Abstract 1244 -The Impact of Repeat Biopsies on Infectious Complications in Men with Prostate Cancer on Active Surveillance: a Prospective Study

Another Dispatch from the Front

BY RALPH BLUM

In my Blog “Nervous Moments” I wrote about the sinking feeling in my gut—half panic, half “Oh s--t!”—when I learned that my PSA had spiked to 26. Since then I have done a course of Cipro, in order to determine whether the hike was a result of an infection (Jeanne and I had both had the flu). And I made an appointment with Dr. Duke Bahn for a color Doppler MRI.

If I had a significant bout of the flu, it wasn’t severe enough to effect my PSA which, on re-checking after the course of Cipro, was undiminished. The result of Dr. Bahn’s test showed a small but discernible progression of the cancer. Not what I wanted to hear, and as a result of his findings (pointing out on the images the enlarged dark cancer patches) I began to entertain serious thoughts of finally getting treated. But before determining the type of treatment I had to determine that the cancer hadn’t spread to my lymph system, or to my bones.

So it was back into the clickety-clack, thumpa-thumpa-thump of the MRI machine, with Vivaldi’s “The Four Seasons” soothing my ears. I admit, I rather enjoy the contrast: flutes and strings and kettle-drums. Directly following the MRI, I went next door for a bone scan.

The first results were provided by the same dayfollowed  the next afternoon by the results of the bone scan (“No evidence for any spread of cancer.”)  The news was great. Both were clear. Big sigh of relief. Thank you, God! So now the question is: to treat or not to treat? I started this journey back in 1990 when I was 58 years old, and apart from 15 months on hormone blockade (a single drug protocol with Lupron when my PSA last spiked in 2003), I have monitored my cancer with Active Surveillance. And now, at eighty I still have options.

I’m still in the process of decision-making. But I’m getting tired of the uncertainty, and I’m leaning toward placing myself in Dr. Lisa Chaiken’s competent hands. Dr. Chaiken is the chief radiation oncologist at the Santa Monica Treatment Center, a state-of-the-art facility for Intensity Modulated Radiation Therapy (aka IMRT) at St. John’s Hospital in Santa Monica.

So, finding myself at the decision point once again, in my next Blog, I will take a closer look at IMRT.  The odds are that it will become my treatment of choice.

Life After Combidex (Part 1)

BY RALPH BLUM

A few days ago I got an email bemoaning the demise of Combidex, and asking for a review of the situation, including what replacements were on the horizon. So in this Blog and the next, I will attempt to shed some light on the matter.

The most common areas of prostate cancer metastasis are the pelvic or abdominal lymph nodes and the bones, but detecting whether the cancer has spread to the lymph nodes is a problem, because no truly reliable diagnostic test for lymphatic involvement is currently available.

In 2007, when my Gleason score had gone from 6 to 7 and the cancer had arrived in the left seminal vesicle, I traveled to the Netherlands for a Combidex MRI. According to the makers, Advanced Magnetics, Inc. (now AMAG Pharma), Combidex, the brand name for ferumoxtran-10, could “assist in the differentiation between metastatic and non-metastatic lymph nodes in patients with confirmed primary cancer who were at risk for lymph node metastasis.” How it worked was that metastatic lymph nodes showed less “uptake” of the iron oxide nanoparticles. Fortunately for me, all my lymph nodes were clear. However (and it’s a long story that I detailed in Invasion of the Prostate Snatchers) the Combidex infusion MRI, by far the most reliable (better than 90% accurate) diagnostic test for lymph node detection, didn’t make it past the FDA watchdogs, and AMAG Pharma discontinued the production of ferumoxtran-10. So the Combidex MRI is presently no longer available anywhere.

The primary FDA-approved diagnostic test for detecting lymphatic involvement is the ProstaScint scan. Given by an intravenous injection, ProstaScint circulates throughout the body and attaches to prostate cancer cells. The injection contains a small amount of low-level radioactive material that is absorbed by the cancer cells and shows up as “hot spots.” But the findings are subtle, with a high risk of false positives, and an absolute necessity with the ProstaScint scan is an extremely experienced interpreter.

Meanwhile in Holland, Dr Jelle Barentsz, Professor of Radiology, UMC  St. Radboud,  Nijmegen, has been working on a validation study of Feraheme (made of nano-particles of iron) as a lymph node diagnostic agent. Feraheme is the contrast agent with which AMAG Pharma replaced Combidex, and Dr. Barentsz’ study is to find out if Feraheme is as good a contrast agent as Combidex. Currently Feraheme is only approved for treating patients with iron deficiency anemia or chronic adult kidney disease.

We desperately need better tests. The ability of oncologists to accurately detect lymph node involvement could signify a huge step forward in staging and, therefore, in making optimal treatment decisions for men with newly diagnosed and advanced prostate cancer.

Successful Mentoring Means Everybody Gets Their Needs Met

BY RALPH BLUM

The matter of finding men able and willing to guide newly-diagnosed men who attend support groups requires considerable thought. Leaders often deal with very challenging situations.  For example, how does one handle the men who are attending with a single overriding need, the need to have their personal experience and their treatment decisions validated?

These “confirmation seekers” do not understand how their need for simple black and white declarations distorts the real challenges faced in selecting treatment. The reality with prostate cancer is that it is possible to have a bad outcome even though the “best” treatment may have been selected.

All prostate cancer treatments are potentially dangerous, placing a man’s quality of life in serious jeopardy.  All that the “best” treatment can offer is better odds,  a less risky alternative compared to the options. Guarantees of success are made by charlatans and believed by suckers. 

So in Lenin’s famous words, “What is to be done?”  The dilemma support group leaders face is to address the needs of all the individuals even though their needs may not relevant to the whole group. The solution came from an old friend, David Derris, a man whose decades of experience in guiding support groups have resulted in a sensitive and bias-free skill-set.

According to Dr. Derris a support group leader needs to somehow get across to the newly-diagnosed that scientific information about different treatment options only provides general guidance, not absolute answers.  How does he go about accomplishing this? Derris provides a simple solution: If the support group begins at 7 PM, he invites all new patients members come at 6 PM, an hour earlier. By providing the newly-diagnosed patients a separate session, all options can be discussed free from any pressure from the “confirmation seekers.”

Many newly-diagnosed men have a low-risk situation—a mildly elevated PSA, or a Gleason score of 3 + 3—which makes them candidates for active surveillance rather than immediate treatment. The field of active surveillance is dynamicly changing. New studies suggest that multi-parametric MRI approximates the accuracy of a needle biopsy.  These rapid changes in the way medicine is being practiced demand an open-minded approach in a collegial environment. A low pressure situation excluding the highly opinionated enables newly-diagnosed men to think more clearly and increases their self-confidence.

At the same time, no group wants to lose those experienced men, simply because their agenda includes confirmation of their own treatment decisions. These guys who have “been there, done that” and lived to tell their story have a valuable role to play as witnesses and informants. Sharing their experiences can provide long-term perspectives for the newly-diagnosed. Dr. Derris is to be commended for finding ways to ensure that all members of the group will have their needs met.

I was pleased to learn from Mark that those who now serve, or wish to serve, as support group leaders can, thanks to PCRI, sign up for a course in  “Mentoring” www.pcrimentors.org where they can learn from  the experiences of the best advocates in the field, men like “Snuffy” Myers, Mark Moyad, and John Blasko. Good news and more to come.

“Good” Prostate Cancer, “Bad” Prostate Cancer

BY MARK SCHOLZ, MD

How can anyone call a cancer “Good?” As time goes by, it seems that prostate cancer is becoming more confusing, not less. Many of us have heard the statement that, “Men die with prostate cancer, not from it.” Or another commonly repeated statement, “The treatment is worse than the disease.”

But then we hear about Merv Griffin or Dennis Hopper, men with immense financial resources, dying from prostate cancer.  How can we say that prostate cancer is “Good?”

When someone hears the word CANCER, they think they know what you are talking about.  Cancer is so common that it now vies with heart disease for being the most common cause of death in men. Cancer has touched the lives of most people, usually in a very negative way.

Perhaps the best way to get a feel for prostate cancer is to compare the “Bad” type of prostate cancer with cancer of the lung or colon, the other two most common types of cancer in men. Other cancers of the brain, bone, stomach, pancreas, kidney and bladder tend to behave in a way that is similar to lung or colon cancer.

	Lung, Colon Cancer	“Bad” Prostate Cancer
Blood test available for early detection	no	yes
Hormone therapy available	no	yes
Spreads to liver or brain	Yes	no
10-year survival rate	10-50%	90%
Average survival after relapse	1-2 years	More than10 years

Since the table tells us that it’s far better to have a “Bad” prostate cancer than just about any other type of cancer, imagine how confusing it is when people are told they have a “Good” type of prostate cancer.  What the heck does that mean?

Men are encouraged to refrain from fearing Low-Risk or “Good” prostate cancer because their life expectancy is identical to or even better than that of men who have never been diagnosed with prostate cancer, even without treatment. Since the survival rate is excellent, immediate administration of toxic therapies that ruin sexual and urinary function is inappropriate and often reprehensible.

There is a question that frequently arises: “How accurately can doctors discriminate between the good and bad types of prostate cancer? Do they ever make mistakes and advise men with “Bad” prostate cancer to forgo immediate treatment?

Until fairly recently, men with “Bad” prostate cancer were misdiagnosed because standard prostate biopsy techniques do not routinely sample the front half of the prostate gland.  While cancer in the front of the prostate is uncommon, and because the area is not routinely biopsied, high grade cancers could be missed.  Fortunately, recently developed imaging with multi-parametric Magnetic Resonance Imaging (MRI) can now detect high grade disease in the front or anterior half of the gland with a high degree of accuracy.

Imaging with MRI is so improved that preliminary studies presented in Atlanta at this year’s meeting of the American Urology Association indicate that multi-parametric MRI may be able to replace biopsy altogether.  I am planning to review these exciting reports in my next blog.

Keeping a Folder of your Medical Records Gearing Up for Your Prostate Cancer Journey (Part 2)

BY RALPH BLUM

It is very important, once you are diagnosed with cancer, to obtain copies of all your medical records, both for your own understanding, and so that you can make copies for the specialists you might want to consult. The following is a list of the reports and test results that you need to keep in your medical folder.

Start by making a chronological log of all your PSA tests with dates, and note in the log any general health changes or treatments that might impact your PSA.

Then obtain the following:

·         A copy of your urologist’s notes that discuss the results of your Digital Rectal Exam (DRE).

·         A copy of your urologist’s Transrectal Ultrasound (TRUS) report that lists the size of your prostate in grams or cc. It may also indicate other findings that are part of your biology.

·         A copy of your Biopsy Pathology Report. This should provide your Gleason Score, how many cores were positive, the extent of disease in the cores, and possibly other important clinical diagnosis information such as the location of the cancer within the prostate gland. It is also wise to retrieve your biopsy slides from the pathologist and send them to a world-class cancer treatment center, such as MD Anderson, Johns Hopkins, or Cedars Sinai, for a second opinion. In fact if you live in a small town or in the country, if possible you should find a urologist at one of the major centers for a consultation before making a treatment decision.

·         Get copies of the written radiology reports for any scans (color Doppler ultrasound, bone, CT, MRI), and get digital copies of the actual scan if available. These are necessary for any future radiologist who will want to compare them with new scans.

·         Lastly, it is advisable to include in your medical folder copies of all information regarding your medical history, including any current (unrelated to the prostate cancer) health problems, even if they seem minor. Also, a printed list of all your medications (along with the dosages) and any supplements you are taking.

If all this seems overwhelming, ask your partner to help you create a medical folder. Finding out that someone you love has been diagnosed with prostate cancer is a devastating blow. Your partner also feels worried and scared and helpless. Having something constructive to do, like organizing your medical information, can help her (or him) obtain some feeling of control over the prostate cancer.

Creating this Medical Records Folder will save you time and anxiety. Much of what you have read here comes from the advice of my writing partner, oncologist Mark Scholz, and can also be found in more detail in the pages of the Prostate Cancer Research Institute (PCRI) Papers and Newsletters.