Archive for the ‘a urology in gainesville georgia’ Category

Podbean thoughts on “sapping up” all you can from everyone before you make your “decision.”

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if you point your finger at someone...there are three pointing back at you....or seeing sawdust in another's eye when there is a log in your own

The above illustration is from “The Decision” now the number one book on Kindle for the subject of prostate cancer on amazon.com

“But I don’t have any voiding symptoms doc.”

“A little knowledge is a dangerous thing.”

Podbean podcast prostate diaries…….minute on the subject and this silly and trite objection

An interesting question on Podbean

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don't put off today for tomorrow...tomorrow has its own problems



Clarion ForeW0rd Five Star Review of “The Decision.”    

 Not too shabby!


The Decision: Your prostate biopsy shows cancer. Now What?
John C. McHugh



Five Stars (out of Five)

There is very little that is more startling than getting a call from a doctor with the news that the
diagnosis is cancer. A recent article indicated that 200,
000 men are diagnosed with prostate
cancer in the United States every year; 25,000 die of the disease. Dr. John C.
McHugh, an
experienced urologist and surgeon, brings a rational, no-
nonsense approach to the decision
regarding treatment for prostate cancer in The Decision: Your prostate biopsy shows cance
Now What? McHugh knows of what he speaks: Not only has he couns
eled men with prostate
cancer in his urology practice for more than 25 years,
but he himself was diagnosed with the
disease at age 52 and experienced the gut-wrenching decision that is the subject of his book.

Importantly, Dr. McHugh does not overwhelm the reader with too much information. He
is writing for the man who already has been diagnosed with prostate cancer. “Right now,
don’t need a big, comprehensive book about the causes and intricacies of prostate cancer;
that is
irrelevant to you.” What a man at this point needs is specific information about hi
s options for
treatment that is relevant to his particular circumstances.

According to McHugh, the man diagnosed with prostate cancer needs to know about his
cancer, his general underlying health condition, and the best treatment options available to him.
While the author is a urological surgeon,
he is not biased toward a surgical solution. He
recognizes that there are valid reasons for choosing other options for treatment,
such as radiation
and seed implantation. McHugh gives a detailed discussion of the pros and cons of each mode of

treatment in language easily understood by the layman. Along the way, the author relays various
experiences he and others have had in the course of selecting a treatment.

Significantly, the author describes and discusses the various side effects of each of the
treatment options he lists: surgery, radiation and seed implantation. Considering only the
treatment procedure without its attendant side effects is only half an analysis, he believes.
radiation treatment is quick and easily administered and allows the patient to return to
work sooner than surgery.
But radiation can also complicate pre-existing voiding problems and
may have longer lasting and uncertain detrimental effects.

McHugh has written an invaluable tool for the man facing the decision of how to treat his
prostate cancer.

This reviewer too knows of what he speaks, having been diagnosed with prostate cancer
nearly six years ago. He had robotic surgery and is living an active, cancer-free life.

John Michael Senger


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the concerns of the heart are easily seen in the countenance of the face

  • A lot of what folks do depends on “who they are.”  The anxious patient may want to pursue a biopsy the first time it is elevated. The idea of waiting a couple a weeks and maybe a course of “empiric” antibiotics is something they don’t want to do. Another “calmer” type patient might wait months or as I have seen,”I’ll just repeat it at my yearly Doc.”
  • It is always reasonable to repeat any lab value that is elevated. With the PSA, a two-week interval with or without antibiotics is something I commonly recommend.
  • If there is a history of prostate cancer in the family that would make one more inclined to do a biopsy.
  • The rectal exam trumps the PSA…so i the PSA is high and you are questioning the results and you want to repeat it…to most urologists, if the PSA is normal and the rectal exam has an abnormality, a biopsy is usually recommended.
  • If your rectal exam is normal and your PSA is abnormal, say in the 4-10 range and the PSA has been about the same for years…you might not consider a biopsy.
  • It is my opinion that a persistently elevated PSA should warrant a biopsy at least once. This then rules out prostate cancer and now gives the patient a baseline of “his” normal PSA.
  • It is not unusual at all for some patients to have a high PSA and not have cancer.
  • There are lots of reasons for an elevated PSA besides cancer and that is what makes the question tricky.
  • Since there are some prostate cancers that are aggressive and the PSA is not elevated or only minimally elevated..this is what makes the situation tricky.
  • It is best in all things medicine to consider all factors….i.e. a man 80 with a PSA of 6 is different from a 55-year-old with the same value.
  • Health issues important: In some patients we don’t do a biopsy because if we did and found cancer, in that particular patient we already know we wouldn’t treat it.
  • Sometimes a Free and Total PSA is helpful. A low free PSA % means a higher likelihood of a positive biopsy.
  • Read Lorenzo Squarf’s rationale for not pursuing a biopsy. (Search his name on this site.)

So if your life expectancy is greater than 10 years, you have a confirmed elevated PSA and have not previously had a biopsy…I’d recommend one. You may never need another.

Repeating after a period of time, even up to three months particularly if the rectal exam is normal, is even reasonable.  If it reverts to below normal the likelihood things are good. You still should keep an eye on it. Listen to the urologist, ask your GP his thoughts. Get a second opinion if it is important to you with another urologist. I wouldn’t put much weight into what a friend recommends. He may be smart but he will not know the specifics of your situation, rectal exam and etc.

I watched my PSA for about 6 months before biting the bullet. The Free PSA did it for me…mine was very low.

Take home message to the question: There is certainly no rush…you have time to repeat and consider your options and where and “who you are” in life before making the “prostate biopsy decision.” Always remember this…You are the boss. All doctors can do is recommend and you go along with your willing consent.

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to succeed you just have to get up one more time than falling down......

Product Details

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Podbean Prostatic urethra podcast (say that three times!)

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i love my green egg....put it at 350 and faaaagetttaabout it


Don’t make your prostate cancer decisions based on what “other people” did unless you know “all” about the specifics of them and their disease. “A word to the wise is sufficient.”

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Podbean video podcast on prostate cancer and the reluctant and misinformed male

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nothing is impossible for the man who doesnt have to do it


First of all the PSA as a judge of the status of prostate cancer after treatment is reliable. There is a PSA bump that is sometimes seen after seed therapy which reverts to normal with time. The period of time when the PSA begins to rise, hovers and then goes back down in these patients is a time of anxiety for both the patient and the doctor.

Another potential side-effect of brachytherapy, indeed all forms of radiation, is called the PSA “bump” phenomenon. The PSA “bump” is a delayed PSA rise occurring after the radiation finishes. Although the exact cause of PSA “bump” is not known with certainty, it is believed to result from irritation of the residual prostate gland by radiation. The “bump” follows a benign clinical course and usually resolves itself within a year. The main danger of the PSA “bump” comes when physicians mistakenly conclude that the rising PSA represents recurrent cancer and decide to start ADT when no cancer is present. From PCRI

Well, I don’t much about cryosurgery so feel free to take what I say with the proverbial grain of salt. I do recall that our old friend Richard Albin “discover of the PSA” is a proponent of the cryo-destruction of cancers. Here’s what I do know by having read about it…I have not learned to perform the procedure:

  • It is recommended for the more favorable types of prostate cancer
  • It can be repeated if it fails
  • It can be done if someone has failed external beam radiation, probably not the best idea if seeds have been done
  • It is very operator dependent…probes are inserted and the key is getting all of the prostate “freezed”…certainly one guy may be better at it than the next or if a particular doctor has done 500 vs. one that has done 30.
  • It has a high rate of impotence
  • It appeals to the guy that can’t have surgery and doesn’t want radiation
  • It is usually out-patient or a one night stay
  • It has acceptable complication rates
  • The reason I chose surgery is that ” I knew that all the cancer in the gland would be removed…I did not know for certain that seeds (or any local procedure such as HIFU, NanoKnife, or Cryosurgery) would kill all the cancer in the gland.

Now if you have had cryosurgery for your prostate cancer and after a few years the PSA begins to rise and on rechecking the PSA over time and the PSA continues to rise…this most probably represents recurrence of your prostate cancer. Maybe an area of the cancer was “stunned” but not killed and it is showing its head. What to do?

  • This is where the “who are you” factors come into play
  • An older person with some medical issues would do something differently than a  young guy that is healthy
  • If either category of patient in whom the PSA rises and they want to be treated for cure…the first thing one would do is to prove that the PSA that is showing up is from only the prostate and not from  metastatic spread.
  • This is problematic…a PSA of less than 10 (the very level that one would want to pursue another curative treatment) probably would not show up in the most common staging studies.
  • But anyway…you’d do a Prostatic Acid Phosphatase blood level (this is the study we used to do that was fairly sensitive for spread of prostate cancer beyond the prostate
  • A bone scan looking for bone mets, a CT scan looking for pelvic lymph nodes and then a Prostascint Scan which has a certain degree of false positive and false negatives…may or may not be covered by insurance.
  • I have ordered about five ProstaScint scans. Talking about a hassle. A thousand questions about the patient to help the radiologist look for the cancer, and then all the medical necessity questions from insurance. Marginal helpfulness….
  • So…you jump through all the hoops and you ring all the bells and to the very best of your doctor’s ability…your PSA is going up but it is not from anywhere but the prostate..i.e. not metastatic spread.
  • I  am very familiar with this situation in the post-radiation patient..but not for cryosurgery, but there are some things that are in common and may be helpful
  • A young guy will be more aggressive than an older guy
  • The younger guy might find someone to remove the prostate if he will accept all the risks….remember surgeons don’t like operating on “dirty” tissue planes
  • The younger guy might repeat the cryosurgery or consult a radiation therapist for any options he might offer
  • The younger guy probably would not do hormones of any sort
  • The younger guy might consider the nanoKnife or HIFU

Now the older guy…say late 70′s and moderately healthy and anticipated life expectancy of 10 years. Well this is tricky any why medicine is an “art and not a science.” Options:

  • He’d have to do all the tests to prove it is no where else
  • He could repeat the cryosurgery if his doctor and him agree on the risks, side effects etc
  • He could consult a radiation therapist, consider HIFU or nanoKnife (not FDA approved and expensive)
  • He could do nothing ( a quality of life first type person) and watch the velocity of the PSA change…I had a patient on time whose PSA rose after a prostatectomy to 2.5 and then stayed there….he passed away of something else….I was a pallbearer in his funeral. He had a soldier there playing taps in full uniform….very moving and an honor.
  • Now this is where the urologist and the patient and patient’s family have a long talk and where finesse comes in.
  • Hormonal therapy…options casodex like drugs, LHRH shots, or something that is a mild anti hormone like Avodart
  • Hormonal therapy corrects the PSA (usually) but doesn’t cure the cancer

How nice would it be for the 77-year-old if you could do some sort of  intermittent hormonal therapy that would keep the PSA at bay and not put him through all the tests and another treatment with a whole “nother” set of problems and complications and as well limit the side effects of hormonal therapy.(Hot flashes, breast enlargement)

What if you gave this patient Avodart and for a year or so it keep the PSA from rising…and then if it did you then went to Casodex for a few years. Now we are in our 80′s and all of the other options previously discussed are still available or some new treatment was available or FDA approved.

So tricky huh? What would I recommend if I were the doctor for the older post cryosurgery patient…..I’d do with him like I always do….I’d take my lead from him…If he’s aggressive and knows what he’s getting into we’d discuss curative things.. If he values his quality of life and is okay monitoring the PSA with a mild anti-hormone…we might go that way. We’d consider a second opinion and together come to a plan that suits all. In this case however I’d say the most important factor is the age of the patient. I’d lean away from another curative treatment unless the patient were adamant about it. Tricky tricky.

 Always remember…. Primum non nocere-First do no harm


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burn me once… shame on you…burn me twice…shame on me


  • When tumors are described by way of its differentiation, i.e. well differentiated, poorly differentiated, what they  are talking about is how close or how far away is from a normal one.
  • In prostate cancer the Gleason’s score  is a way to describe how a cell is differentiated.
  • A Gleason 6 is a well-moderately differentiated cancer.
  • A Gleason 8 or above is a poorly differentiated cancer.
  • A well differentiated prostate cancer is harder to call for the pathologist than a moderately differentiated cancer because the well differentiated cell more closely resembles the normal prostate cell.
  • A poorly differentiated prostate cancer cell is  an easy to call for the pathologist because its architecture is so far removed from how a normal cell looks…it is sometimes described as “bizarre.”
  • A poorly differentiated cell however can be tricky for the pathologist because it can be so bizarre looking that it loses all the characteristics of a prostate cell.
  • So if a patient has a lymph node somewhere and the doctors  don’t know the primary cancer (i.e. the origin of the primary cancer) and it is biopsied and it comes back as a “poorly differentiated cancer” the pathologist sometimes can’t tell you where the cancer in the lymph node is from…it is too bizarre to categorize.
  • Poorly differentiated cancers are very aggressive, usually don’t respond well to treatment and the patients that have this type of cancer don’t do as well as those as ones with well differentiated cancer.
  • Gleason’s 6 patients as a rule  will respond to treatment better than a Gleason’s 8 patient.
  • Gleason’s 6 well-mod differentiated , Gleason’s 9 poorly differentiated.
  • If some prostate cancers don’t produce a  high PSA then this makes the case of being sure a rectal exam is always done. That patient who avoids a rectal exam thinking that “I am Okay, my PSA is normal” runs the risk of having prostate cancer and not knowing it.

Now to the question. A poorly differentiated prostate  cancer with bizarre  features under the microscope can be so “cancerous” that it also has lost the functions of  a normal prostate cancer cell.

In this case the most probable reason for a low PSA and an aggressive prostate cancer is that the prostate cancer cell is so bizarre it has lost some of the normal functions of a normal cell and in this case the ability to produce PSA.

Gleason’s score is another way that is prostate cancer specific to describe the differentiation of the cancer and in turn gives one insight to the aggressiveness of their disease.

I have had patients come in for their path report only to find that the pathologist has called one of the cores as suspicious and that more time and stains will be necessary to “call” the diagnosis. I have told them that in some ways this type of report is a good  thing.  I have said, ” The bad cancers are the easy ones to call. So you either don’t have prostate cancer or it will be a low Gleason’s or the good kind.” My fear for my biopsy was not that I would have cancer, but that I’d have “the bad kind…the Frank Zappa kind.”

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