Reduced PSA Testing Leading to Rise in Metastatic Cancer

Ever since the USPSTF (United States Preventive Services Task Force) declared that routine PSA screening was of no real value (a position hotly contested by many in the field) the rate of PSA testing has decreased. Not surprisingly the detected incidence of prostate cancer has also decreased. This was certainly to be expected since if one does not look for occult cancer clearly one will not find it.

The theory was that too many men were getting treated for prostate cancers that were likely not to be lethal and therefore quality of life was being sacrificed for no real gain in life expectancy. Certainly, there is some validity in this view, in that at the time that data was reviewed, our ability to predict which prostate cancers were likely to be lethal versus those that were most likely not to be was very limited. Many critics have cited the historical fact that early detection of cancer (and disease in general) has been an accepted maxim of medical practice and public health measures for many decades.

A new study, recently published in the in Nature, indicates that more men are now presenting with metastatic prostate cancer over the past 8 years. The data review which began in 2007 showed that the incidence of metastatic prostate cancer had increased especially among men in the age group thought most likely to benefit from definitive treatment for prostate cancer. The findings indicated a 72% increase in the number of men initially presenting with metastatic prostate cancer in a select cohort of U.S. hospitals.

Over the same time period as this new study, newer techniques and refinements of data interpretation have occurred which have given the urologist a better handle on identifying those at greater risk of more aggressive disease. Concomitantly, improved concepts of “active surveillance” and “watchful waiting” have evolved which have made a rush to major invasive therapies not as essential when a clearer picture of the aggressiveness of the cancer can be estimated with greater precision.

Certainly, we have not yet arrived at the perfect solution to the question of which cancers need to be treated and which can be observed. However, it is my feeling that not diagnosing potential disease is an error. There is no obligation on the part of any patient to pursue treatment no matter what the diagnosis. Not diagnosing disease however, deprives the patient of information which would allow them to make an informed decision in collaboration with a medical expert.

So it is no surprise that when prostate cancer is detected late, most of those patients would have metastatic disease. This was the case in the vast majority of cases prior to the 1980’s and the advent of the “PSA era”. In my view, the USPSTF recommendations were in error and lacked sophisticated input from experienced urologists active in the diagnosis and treatment of prostate cancer.

It should also be noted for primary care physicians, that failure to diagnose is an actionable event legally, therefore they must document their discussion with patients and the joint decision not to do PSA testing. Failure to adequately do so may leave them open to claims of malpractice and omission of informed consent “not to test”.


Prostate Ca: Are more men presenting with metastatic disease?

Increasing incidence of metastatic prostate cancer in the United States (2004–2013)

Proscar (finasteride) linked to decreased testosterone and ED with long term use


Finasteride, not tamsulosin, increases severity of erectile dysfunction and decreases testosterone levels in men with benign prostatic hyperplasia.

A new article just published in the past week suggests that the long term use of finasteride (Proscar) may reduce testosterone levels (LowT) and lead to erectile dysfunction (ED).  The finding of ED is not surprising, as this side effect was known from early clinical studies. The finding of LowT is somewhat surprising. These results suggest that men who are taking finasteride for the treatment of prostate enlargement (BPH) may do just as well, with fewer side effects, by taking another class of drugs, in this case tamsulosin (Flomax).  Earlier studies did show that the combined use of tamsulosin and finasteride was superior in terms of treatment of BPH to either one alone. However, in light of new evidence, a more tailored approach is likely to be needed based on findings in an individual patient.  These findings would include the degree of obstruction as demonstrated endoscopically and via voiding studies (urodynamics) as well as the patients ability to empty the bladder combined with a symptom score index and bother score.

This should not be confused with men who were studied using finasteride for prevention of prostate cancer. While this medication and dutasteride (Avodart) have been shown to be effective in preventing some prostate cancers, these drugs are not currently FDA approved for chemo-prevention of prostate cancer. In cases where men are at increased or high risk of prostate cancer due to family history, ethnicity or specific lab or pathology findings, the implementation of these drugs in this fashion should be undertaken only after careful discussion with the patients urologist.

Traish AM, Haider KS, Doros G, Haider A. Finasteride, not tamsulosin, increases severity of erectile dysfunction and decreases testosterone levels in men with benign prostatic hyperplasia. Horm Mol Biol Clin Investig. 2015 Jun 6. pii: /j/hmbci.ahead-of-print/hmbci-2015-0015/hmbci-2015-0015.xml. doi: 10.1515/hmbci-2015-0015. [Epub ahead of print]


Spinal stimulation helps four patients with paraplegia regain voluntary movement

Groundbreaking results bring new hope for those with spinal cord injury – NIH study

Amazing new data just released from the NIH regarding a new study funded by the Reeve Foundation.

This study showed that patients were able to regain VOLUNTARY movement of their lower limbs after spinal cord stimulation and that the effects were enhanced by the addition of physical therapy and continued mobility. 

Hopefully, the beginning of a major breakthrough in our ability to treat and rehabilitate those with major spinal injuries due to trauma, disease or needed surgery.

Vaccines Have Reduced Communicable Diseases Dramatically – Their Use is Major Positive Public Health Success

From Vaccine News Net . . . When we have children, we all hear a lot about vaccines and vaccine safety. It’s critical for your child’s health that you know the important facts. The bottom line is that vaccines preserve life and livelihood; the science is clear on that. Do We Really Need Vaccines? ABSOLUTELY

What’s the real story on vaccines?

Click on this link to see the impact on vaccines in the reduction of common communicable diseases which have historically been the cause of much morbidity, disability and mortality.  Today they are in most cases, absent or barely present among the global population.

MRI Guided Prostate Biopsy Improves Diagnosis in Men with Previous Negative Biopsies but Persistent Elevated PSA Levels

This article overviews the use of MRI as an adjunct to aid in diagnosis in men who show a persistently elevated serum PSA level but have had negative prostate biopsies via conventional ultrasound guided techniques.

The study’s authors conclude that conventional biopsy fails to detect the presence of some prostate cancers (PCas). Men with a prior negative biopsy but persistently elevated prostate-specific antigen (PSA) pose a diagnostic dilemma, as some harbor elusive cancer.

MR-US fusion biopsy provides improved detection of PCa in men with prior negative biopsies and elevated PSA values. Most cancers found were clinically significant.

Sonn GA1, Chang E2, Natarajan S3, Margolis DJ4, Macairan M2, Lieu P2, Huang J5, Dorey FJ6, Reiter RE2, Marks LS2.Value of Targeted Prostate Biopsy Using Magnetic Resonance-Ultrasound Fusion in Men with Prior Negative Biopsy and Elevated Prostate-specific Antigen. Eur Urol. 2014 Apr;65(4):809-15

Physicians Brace for Drug, Device ‘Transparency’

Physicians Brace for Drug, Device ‘Transparency’

Doctors groups are alerting members to be prepared to respond to public disclosures as pharmaceutical and medical device manufacturers begin tracking and reporting their financial interactions with physicians…

This situation will create more problems than it may appear to solve in the long run. Most device makers and drug manufacturers rely on physician input to help create their products. A doctors time is worth something. They deserve payment for their input, ideas, research and educational activities on behalf of any company, society or academic group.

Unfortunately, the continued stigma being attached to these relationships will likely chill the atmosphere such than many physicians will not assist in these activities.  Even though, the activities and compensation are legitimate, legal, ethical and moral.

Transparency is a good thing. Yes, there have been abuses by both industry and physicians but these are a small minority of incidents overall.  We can only hope that so call “transparency” weeds out the bad actors on all sides but does not do too much harm to appropriate collaboration.



Physician Burn Out Rising, Adding to MD Shortage

A recent study published in the Archives of Internal Medicine raises alarms about stresses being  placed on physicians in the current health delivery system.  Symptoms of burnout are far more common among physicians than other workers. Physicians who specialize in front line and primary care services are at the greatest risk.

The findings of the study raise many concerns.  Levels of burnout in US physicians are extremely high; primary care providers and emergency providers seem at the highest risk; physicians work longer hours than other workers; physician have greater struggles with integration of work and life issues than other workers; in fields outside of medicine, high levels of educational attainment seem to be protective against burnout, but this is not the case in medicine. Burnout among physicians is a unique entity and does not reflect societal trends.

Serious personal consequences can result from physician burnout. These can include problematic alcohol use, broken relationships, and suicidal ideation.  Increasingly there is a consensus that burnout can effect quality of care. These findings suggest an alarming problem of systemic proportion for the health delivery system as a whole.

With an almost 50% rate of burnout symptoms reported in US physicians it is clear that the etiology of this problem is within the care delivery system itself.

This fact has important implications for policy makers and health delivery systems which must address this issue head on, for the sake of physicians, patients and the delivery system as a whole.

Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population

COMMENTARY: Taken on face value, one could argue that this is nothing new.  The practice of medicine has always required intense training, dedication and neglect of many of the things in life that others take for granted.  Having said that, the environment today has never been more challenging.

Physicians are subject to an endless barrage of demands which include: certification and repetitive re-certification, medical-legal exposure with every patient encounter, ever growing demands for documentation of ALL aspects of the interaction with patients, ever growing demands for translation of clinical interaction into complex coding language in order to bill and “hope” for payment, skewed and arbitrary fee schedules and payment policies which vary widely between state, federal and private payer entities.

The ability to order lab work or imaging studies for what may seem a straightforward clinical case, can turn into hours of added work via the telephone, fax or email with payers insistent on limiting the amount of care delivered.  These added services are NOT compensated financially and place excessive demands on physician time.

Added to this are the long hours, natural human stresses associated with dealing with ill or injured patients and their families, as well as the emotional toll of having to make major decision, often in a split second, and then being second guessed endlessly by peer review, insurers, or legal review.

Sadly, there is essentially nothing in the recently passed Affordable Care Act (ACA) which will be of much assistance to physicians.  In fact the ACA will add multiple layers of additional burdens in terms of documentation, peer review, and patient volume expansion.  Of even greater concern, is the fact that many of our most seasoned and experienced physicians and surgeons are looking for early exit opportunities in order to leave what they view as a declining practice environment.

Burnout and career satisfaction among American surgeons

Why do surgeons consider leaving practice?

Side Effects of Treatment for Prostate Cancer Persist

A recent study published in The Journal of Clinical Oncology shows that up to at least 10 years after treatment for prostate cancer, men report continued urinary and sexual problems.

Patients who had surgery were about twice as likely to indicate long-term urinary and sexual problems as men receiving radiation therapy. However, men undergoing radiation had a higher risk of bowel complications.

Those who underwent various forms of hormone ablation indicated, not surprisingly, symptoms related to this treatment including sexual dysfunction and other constitutional symptoms.

These findings are neither totally new nor surprising.  Once injury occurs within the confined area of the pelvis occupied by the prostate gland it is likely to persist in the form of injury related symptoms. These include usually stress incontinence and erectile dysfunction. Hormone ablation can induce loss of muscle mass, energy, libido as well as gynecomastia.

To date, despite the excellence of PSA in identifying those likely to have a positive biopsy that shows cancer, we remain unable to identify specifically those men for whom major interventions offer the most benefit in terms of survival.

Additional new tests are in the works to help identify those men with cancers that are likely to be highly active and lead to morbidity and mortality.  Until these become perfected and widely available, urologists and patients must rely on an array of factors to determine the best course of treatment (which can include watchful waiting, better termed active surveillance).  Age, co-morbidity, family history, social history among other factors, all must be carefully considered as well as PSA levels and biopsy results.

Long-Term Disease-Specific Functioning Among Prostate Cancer Survivors and Noncancer Controls in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial



High Blood Pressure Leads to Stroke: Take Your Meds!

A recent presentation last month at the International Stroke Conference held in New Orleans shows that high blood pressure is poorly controlled* in the United States.

Study findings indicated that the rate of compliance with therapy for hypertension as well as the control of blood pressure remained poor in those who had survived a stroke.  In fact, data showed that 50% of stroke survivors have poorly controlled hypertension. Several medical and lifestyle modification factors could be potential targets of intervention to bridge this evidence-practice gap.

A number of factors related to medical intervention and lifestyle were noted.  Patients who were older, female, Hispanic and had diabetes were all found to have increased incidence of poorly controlled blood pressure.

Study subjects who had a previous myocardial infarction (MI, heart attack), used alcohol and were overweight/obese were also less likely to have controlled blood pressure.

Elevated levels of cholesterol as well as being male were both indicators of non-treatment or non-compliance with regimens of anti-hypertensive medications.

However, those who were active smokers and identified as overweight or obese were found to be more likely to have treatment.

Patients who took there blood pressure medicines had lower death rates from all caused when reviewed in absolute terms, but in terms of the study these finding were not statistically significant. Yet, the findings are clearly intriguing.

Of all risks for stroke, high blood pressure is the one that is most able to be controlled and the most amenable to intervention.  Accordingly, efforts to increase diagnosis, early treatment, compliance with medication, diet and lifestyle changes are all essential in reducing the risk of stoke overall, and of recurrent stroke in those previously afflicted.

* poorly-controlled BP (>140/90) and non-treatment

Abstract 3356: Half the Stroke Survivors in the United States have Poorly Controlled Hypertension: Amytis Towfighi; Daniela Markovic; Bruce Ovbiagele; 2012 International Stroke Conference, American Stroke Association, New Orleans

Lack of Sunlight and Temperature Extremes Predispose to Stroke

The effect of sunlight and temperature were explored during a recent presentation at the International Stoke Conference held in New Orleans, February 2012.

The authors noted that the incidence of stroke is higher in the winter.  This suggests that reduced exposure to sunlight may play a role in the increased incidence of stroke.  It is also noted that extreme temperatures, low or high, can increase the risk of stroke.

This study confirmed the finding of the effects of extremely high or low temperatures in leading to an increased incidence of stroke.  They also confirmed the correlation between reduced exposure to sunlight and an increased occurrence of strokes.

It is unclear what the biologic action is that causes strokes to occur more frequently in wintertime. However, we could speculate that it may have to do with an increase in sedentary lifestyle and lack of exercise with subsequent weight gain. Another factor to consider is possible altered sleep patterns brought on by changes in circadian rhythms.  While definitive causation cannot be determined at this time, it is good to be aware of the fact that extreme temperatures and lack of sunlight are factors to be considered in possible stroke prevention strategies.

Abstract 2591: Relationship Between Sunlight and Temperature Exposure to Stroke Incidence in the Reasons for Geographic and Racial Differences in Stroke (regards) Study [Session Title: Community/Risk Factors Posters I]