“We Must do Better,” A Position Statement Regarding PSA Screening from Dean Foster, MD, PCRI Medical Director

Last May, the U.S. Preventative Services Task Force (USPSTF) triggered a firestorm of debate after issuing its recommendation against the use of the prostate-specific antigen (PSA) blood test to screen for prostate cancer. In her editorial responding to the controversy, Task Force Chair, Dr. Virginia Moyer summarized the committee’s findings with this sentence, “We can do better.” The Prostate Cancer Research Institute (PCRI), while disagreeing with the Task Force’s simplistic banning of PSA, does agree with Dr. Moyer’s conclusion: We can indeed do better.

“We can do better in educating men on the pros and cons of PSA,” explains Dr. Dean Foster, the PCRI medical director and prostate cancer survivor. “However, all the recent controversy is giving men an excuse to tune out about a disease that affects one in six of them. The subject of prostate cancer already makes men uncomfortable.  The controversy over the PSA test gives them one more reason not to pay attention.”

The PCRI encourages men to learn about PSA testing in consultation with their physician. When PSA screening is implemented and elevated levels are detected, further education is necessary before undergoing biopsy. For men with a high PSA, the PCRI currently recommends two additional tests prior to undergoing biopsy: PCA--3, a widely available urine test, and multi-parametric MRI. The PCRI offers free Helpline services to aid men in locating centers offering these services. 

Finally, Dr. Foster concludes: “Men can receive the benefit of PSA screening and still protect themselves from the risk of overtreatment, which is the main factor cited by the U.S. Preventative Services Task Force for giving PSA a “D” rating. The PCRI stands in agreement with Dr. Moyer and the USPSTF in that ‘we all must do better.’  However, PCRI does not recommend simply abandoning PSA screening. Through education, unnecessary overtreatment of the benign type of prostate cancer can be avoided while still using PSA to detect the aggressive form.”

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.

The PCRI’s New Medical Director

BY MARK SCHOLZ, MD

The Prostate Cancer Research Institute (PCRI) was co-founded by Dr. Stephen Strum and me in 1996. I have been volunteering as the PCRI’s Executive Director and Medical Director since 2007. I stepped into this dual role suddenly when our previous director, Brad Guess, passed away in 2006 from a heart attack.  As Executive and Medical Director, it has been my responsibility to fulfill PCRI’s stated mission, i.e. to improve the quality of men’s lives by supporting research and disseminating information that educates and empowers patients, families and the medical community.

Thanks to the excellent work of Angelique Guarneri in 2010, and subsequently the work of Cathy Williams who took over as Chief Operating Officer in 2011, PCRI has been growing quickly.  New programs include the Online Blue Community, The Mentor Curriculum and the Play for Blue Fundraisers, all of which operate in addition to existing programs, newsletters, website, helpline, and our annual conference.

Several new people have joined PCRI: Madhu Rajaraman, Staff Journalist; Laurie Sorrow our Programs Director; and Silvia Cooper our newest Helpline Counselor, who works alongside our longstanding Helpline Counselors, Nathan Roundy and Jan Manarite. Also part of the PCRI team includes Tom Gallatin, our Grant Writer, and Angelique Guarneri who now serves as a Social Media consultant.

With the creation and growth of these new programs, my functioning in the dual role of Executive Director and Medical Director has become far too demanding.  In fact, I have become concerned that without a fulltime Medical Director, PCRI’s continued growth and progress will be impeded.

Therefore, as of September 1st, Dean Foster, MD has been hired as the new Medical Director of the PCRI.  Dr. Foster’s resume is too extensive to review in detail. Briefly, he was educated in molecular biology at the University of California in San Diego (UCSD). He studied medicine at USC where he also completed residency in orthopedic surgery. Before retiring from medical practice to pursue missionary work, Dean was a specialist in reconstructive surgery in La Jolla and on the clinical faculty at UCSD. Having known Dean personally for many years, I am thrilled that he is willing to assume the leadership of this vibrant and growing organization. Please join me in welcoming him as the PCRI’s new Medical Director!

I plan to continue my labors to ensure the fulfillment of PCRI’s mission.  I am looking forward to working closely with Dr. Foster to assure the continued expansion and success of the PCRI. 

Introducing Color Doppler Ultrasound

BY RALPH BLUM

Accurate information about the status of your prostate cancer is essential for determining whether you need treatment, or whether you can safely continue with active surveillance. Although some centers of excellence like Memorial Sloan-Kettering and the University of California, San Francisco, use spectrographic MRI, most urology practices still rely on repeated random biopsies as their primary form of monitoring—despite the risks and discomfort involved.

As I have said before, I am no fan of biopsies. As far as I am concerned biopsies are a necessary evil. But under no circumstances should men allow themselves to be rushed into having one before less invasive diagnostic methods have been explored. Having said that, a S-MRI means traveling to a specialized facility, costs a small fortune, and involves having a probe that is called an “endorectal coil” inserted up your butt to improve the image quality.

Fortunately, there is another form of prostate imaging—color Doppler ultrasound—that is considered comparable in quality to S-MRI. It is also easier to perform, takes less time, can be done in the doctor’s office (Prostate Oncology Specialists, Mark Scholz’s office, has color Doppler capability), and requires a much smaller probe than the S-MRI. Big plus! Color Doppler ultrasound provides higher resolution images than the usual gray-scale ultrasound machine, and also “sees” areas of new blood vessel formation (angiogenesis) associated with higher-grade, more aggressive prostate cancers. (I will look more closely at this process in my next Blog.)

Color Doppler ultrasound will, in time, be widely used in clinical practice to evaluate blood flow through organs or tumors. Thanks to its simplicity, ease of use, speed, and safety, ultrasound imaging is being increasingly employed to monitor angiogenesis for diagnosis, treatment assessment, follow-up, and therapy guidance.

All monitoring tools have limitations, including biopsies. Color Doppler is only one of many tools that provide useful information about the status of cancer in the prostate. It was from the color Doppler imaging of Dr. Duke Bahn back in 2008 that I learned the reassuring news of no new blood flow and the stalled growth of my tumor. This accurate feedback, confirming how my cancer was behaving, made it safe for me to continue to watch and wait and avoid radical treatment. A blessing for which I will always be grateful.