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The following is a comment to a previous post- Who regrets prostate treatment worse…

I did my due diligence after diagnosis at age 54 and decided on surgery first, salvage radiation in case of recurrence. Because I was well informed, my oncologist/surgeon was extremely honest and blunt. With my high PSA (40.98) and short doubling time he would be performing a non-nerve sparing Laparoscopic radical prostatectomy. This would result in no possibility of spontaneous erections following surgery. He would do his best to preserve continence. And if he couldn’t get a good ‘feel’ through the Laparoscopic tools, he would cut me open and ‘gut me like a fish’ to ensure the best possible outcome… life. Surgery was performed in November of 2008.
It took 3 months to get continence back. There have been no erections, even using trimix.
In June of 2011 my PSA started to rise, and in June of 2012 I underwent 40 radiation treatments. Both my primary oncologist and radiation oncologist explained the probable loss of continence and probable chronic colitis following radiation. The only adverse reaction is chronic colitis, but I am still in remission.
I do not regret having surgery, radiation, or the 6 months of hormone therapy post surgery. Based on the aggressiveness of my cancer I would probably be dead without all of the therapies. It’s important knowing all possible outcomes (death, complications from infection and scarring, incontinence, and erectile dysfunction) to make a decision that is right for you.
I have an acquaintance who is dying from aggressive prostate cancer. He was diagnosed with late stage cancer at 64, after not seeing a doctor for 15 years. For anyone in remission, no matter what symptoms we have as a result of treatment, those symptoms are a cakewalk compared to what my acquaintance is going through.

Something to think about.

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From Urological Wit and Wisdom

Chapter 56

If I Am Going to Be Impotent Then I Am Going to Look Impotent

 

Okay, there is a classic urology joke that every urologist should have in his armamentarium and never fails to get a good laugh.

A man walks into a vasectomy clinic for his vasectomy all dressed up to the hilt. He has on a tuxedo, top hat and has a walking stick laden with diamonds. He was quite the dandy.

He begins the sign in process with the check-in nurse. She notices his unusual attire.

“Sir, why are you so dressed up for a vasectomy,” she says.

He replies, “If I am going to be impotent I want to look impotent.”

 

Rule: Impotency relates to the inability of having an erection. Libido relates to sex drive and is dependent on testosterone which is produced by the testicles and released into the bloodstream. Fertility is having the presence of sperm in the ejaculate. A vasectomy causes sterility and does not affect testosterone. To neuter one would be cutting off the testicles which do affect testosterone. Once a male goes through puberty and the voice deepens, doing an orchiectomy (or vasectomy for that matter) will not make his voice high, i.e. talk like a girl. Most of the ejaculate is produced by the prostate and not the testicles. An orgasm is caused by the violent contraction of the external sphincter.  You could explain all this to the patient so that he can defend himself from his coworkers when they find out he is having a vasectomy…or you could just tell him the joke and move on. Despite all of this and that the punch line has no medical basis and works only because of the male’s lack of understanding of their genitourinary system, the joke is still universally funny and should be employed on a regular basis.

“Eunuchs do not take the gout, nor become bald.”-Hippocrates

a-mri

I’m reading a book about Edison suing Westinghouse in the late nineteenth century and the development of alternating current. The Serbian who “conquered” alternating current was a idiosyncratic man named Nikola Tesla. It is very interesting however I am in love with the nineteenth century and the men and women of history of that era. Think Twain, Edwin Booth, Henry James, Grant, Kipling, Osler, Roebling, Carnegie, Frick, etc and etc.

So about the study that follows and there are a lot like them. The advent of the MRI for the prostate and what does it mean, does it help, is it really that much better than systematic ultrasound guided biopsies considering the cost and time element.

In a time of all the talk of cost, why is there not more condemnation of the cost of the MRI and the interpretation of it by the radiologist by our “experts.”

Anyway here is the article. Keep in mind I have done thousands of prostate biopsies in my career and the expense of the procedure, the ultrasound, the materials used and what is paid to me for doing is less expensive than an MRI alone. Where is the outrage?

Poor little ole PSA. The Rodney Dangerfield of Medicine. Are the letters MRI more sexually appealing than the letters PSA. Oh by the way…why do you order a MRI in the first place? You guessed it…an elevated PSA…that dirty rascal keeps popping his knarly little ole head…don’t he?

Feel free to opine…if you are well versed in the MRI movement, the benefits, the cost, and why it should be the only study done on men suspected of prostate cancer please…comment. I truly want to be enlightened. Predict the future.

Prostate MRI in the Prebiopsy Setting

Urology – June 15, 2016 – Vol. 34 – No. 3

Prostate MRI in the prebiopsy setting may help identify Gleason 7 and higher cancers.

Article Reviewed: Prebiopsy MRI and MRI-Ultrasound Fusion-Targeted Prostate Biopsy in Men With Previous Negative Biopsies: Impact on Repeat Biopsy Strategies. Mendhiratta N, Meng X, et al: Urology; 2015;86 (December): 1192-1198.

Background: Prostate MRI has seen an explosion of use over the past 5 years. The perceived benefit of prostate MRI is in the identification of high-grade disease and thereby decreasing the overdetection of clinically insignificant prostate cancers.

Participants: Patients presenting to a single institution with elevated prostate-specific antigen (PSA) levels.

Methods: Patients underwent multiparametric prostate MRI with a 3 Tesla unit. Prostate lesions were scored on a scale of 1 to 5, with 5 being very high probability of cancer. Patients with target lesions underwent targeted biopsy with a standard 12-core template biopsy. Patients with a normal MRI were not included in the study, as targeted biopsy could not be performed.

Results: 352 patients were included in the study. Prostate cancer was identified in 207 men. Cancer detection rate was higher in the standard template group (49.2%) than in the targeted biopsy group (43.5%). However, targeted biopsies detected more Gleason 7 or greater disease (88.6%) compared to the standard template (77.3%). Higher volumes of clinically insignificant prostate cancers were detected by standard biopsies. Using suspicion level of 4 and 5, 85.9% of patients were found to have prostate cancer, with 69.1% having Gleason 7 or higher. Using suspicion level 4 and 5, sensitivity, specificity, and negative and positive predictive value were 78.0%, 81.6%, 87.6% and 69.1%, respectively, for finding Gleason 7 or greater disease.

Conclusions: For men with elevated PSA levels, multiparametric MRI is a valuable tool in the prebiopsy setting for detecting clinically significant disease.

Reviewer’s Comments: The authors present compelling data for the addition of MRI in the prebiopsy setting for patients with elevated PSA. What is not included in the study are the data for those patients with negative prostate MRI. In addition, MRI is an expensive imaging modality. Does improved detection of Gleason 7 prostate cancers justify the cost on a population level?(Reviewer–Michael Poch, MD).

 

Author: Mendhiratta N, Meng X, et al
Author Email: samir.taneja@nyumc.org

When the bladder spasms urine will go around the catheter. In the big scheme of things – urine getting out… Is a good thing.

Prostate diaries

When the prostate is removed, the bladder is separated from the urethra (the tube that runs through the penis which men void through). After the prostate is out, the doctor then sews the two areas back together. It takes about 7-10 days for this to heal. A catheter is placed through the tip of the penis in urethra, past the junction of the bladder and the urethra, which has been sewed together, and then into the bladder. A catheter (foley) stays in the bladder by a balloon at its tip. The balloon keeps the catheter from falling out and is about the size of a golf ball.

The bladder does not like the balloon in there. It perceives it as a foreign body and wants to “spit” it out. It does so by contracting as it would to make urine.  This is a bladder spasm and can result in the loss of…

View original post 144 more words

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Ben Stiller’s misguided prostate cancer recommendations aren’t based on evidence-healthnewsreview.org

No it is based on examining the risks of the disease and the risks of the treatment and making a decision he felt was best for him. Regardless of your position on Mr. Psa 30,000 men a year die of prostate cancer. How is that?

Kevin Lomangino is the managing editor of HealthNewsReview.org. He tweets as @Klomangino.

Comedic actor Ben Stiller clearly had the best of intentions when he decided to write about his experience with prostate cancer and urge men to get a prostate specific antigen (PSA) test starting at the age of 40 – advice which contradicts the guidelines of all major professional organizations.

I admire Stiller’s intention to help out help out his fellow man, and I am glad to hear that he’s apparently doing well and satisfied with his treatment choices. I also applaud Stiller for acknowledging the controversy surrounding PSA testing with the following:

The criticism of the test is that depending on how they interpret the data, doctors can send patients for further tests like the MRI and the more invasive biopsy, when not needed. Physicians can find low-risk cancers that are not life threatening, especially to older patients. In some cases, men with this type of cancer get “over-treatment” like radiation or surgery, resulting in side effects such as impotence or incontinence.

That’s important context that’s often missing from similar celebrity health stories — and he also tells men to have a discussion with their doctors about the test. That’s certainly the best way for men to sort through their options and make an informed choice.

My problem with Stiller’s piece is that it makes a number of false or misleading assertions and fails to accurately reflect the evidence on prostate cancer screening. And because Stiller is smart, persuasive, and famous, his skewed piece may do a great deal of harm to men who may be led astray by his faulty reasoning.

NO PROOF that a PSA test saved Ben Stiller’s life

The most glaring problem with Stiller’s argument is that it’s built on a false assumption. He says, “Taking the PSA test saved my life. Literally. That’s why I am writing this now.”

He can’t say that with any certainty.

The facts are these: Prostate cancers vary in their aggressiveness, and some very aggressive cancers will prove fatal despite early detection and treatment like Stiller received, whereas the majority grow slowly and might never pose a problem to the patient. Stiller says his cancer had a Gleason Score of 7, but doesn’t offer full details about his case that would allow experts to assess the likelihood that he’d benefit from prostate removal. Even with those details, it would be impossible to know for certain whether his cancer would have spread or not.

For that reason, no one-including a celebrity with greater-than-normal access to top-notch healthcare–can say whether the test saved his life, or merely detected a cancer that could have been monitored and might never have bothered him.

Here’s how oncologist Vinay Prasad, MD, MPH, explained the flaws in Stiller’s logic to me:

Before embarking on any screening test, a physician MUST council a patient about harms of screening, including false positives and overdiagnosis–where a real cancer is found and treated, but it would not have caused the person problems. Ben Stiller’s strong faith that the test “saved his life” is incompatible with a true understanding of overdiagnosis. If he really understood overdiagnosis, he would understand that he could not say this definitively. Gil Welch has shown that often most people with breast cancer diagnosed by screening cannot claim to have their life saved. The same principles that apply in this study also apply to prostate cancer, and no person whose cancer was found by PSA screening can say definitively, “The test saved my life.”

HealthNewsReview.org contributor Douglas Campos-Outcalt, MD, agreed that the evidence cuts against Stiller.

When someone says “Taking the PSA test saved my life,” they have over a 95% chance of being wrong. There is a spectrum of aggressiveness in prostate cancers. The vast majority detected by screening are not aggressive and screening does more harm than good in these men. The most aggressive forms are not helped (usually) by screening because they are too aggressive and are not asymptomatic long enough to be detected by screening. The moderately aggressive tumors are the only ones that can benefit from screening and the unusual man who has one of these detected by screening may have their life “saved,” but this is offset by the number killed by the treatments and the large number who are left impotent and incontinent.

Here’s an evidence-based infographic from the Harding Center for Risk Literacy that explains the numbers – note that for every thousand men screened, up to 160 false positive tests will occur and up to 20 men will be treated unnecessarily (risking harm from unneeded surgery) with no clear mortality benefit.

 

Although Stiller dismisses those harms – incontinence, impotence, among others — as being “in the purview of the doctor treating the patient” (whatever that means), the fact is that the treatments themselves can be deadly or cause serious disabling side effects. Even the biopsy resulting from a false-positive PSA can lead to serious infections requiring hospitalization and – rarely – death.

In fact, the treatments can be so grueling that it’s possible they may increase other causes of death – canceling out any reduction in prostate cancer deaths. That’s why Prasad and others argue that overall mortality, and not prostate cancer mortality, should be the benchmark to assess benefits from cancer screening.

Celebrities have a responsibility to use their platform wisely

Another problem with saying the PSA saved his life: He might still die from prostate cancer, in spite of being tested. Sadly – and I very much hope this is not the case – it’s possible that Stiller’s cancer is one of the aggressive ones that will recur despite early detection and treatment – meaning that Stiller’s declaration of having his life “saved” will turn out to be premature. This is a reality that needs to be acknowledged. Everyone needs to choose their words carefully when addressing a topic as deadly serious as cancer.

That’s especially true for celebrities, who in our culture have an outsized platform to express their views. Timothy Caulfield, who studies celebrity health messaging at the University of Alberta, calls Stiller’s post “exactly the kind of celebrity advice that is not needed.”

The message that is conveyed by Stiller’s post is that PSA testing is a benign procedure (“it is a simple, painless blood test”) that only has upsides – that is, if you have the right doctor (how a patient is suppose to know this, isn’t clear). But his personal story is not evidence. This is a well-told anecdote, not good data that demonstrates that PSA testing is worthwhile. It is advice that can only confuse the public discourse surrounding PSA testing. More important, it runs counters to the emerging evidence-informed consensus that, for most, PSA screening is not helpful and may be harmful. But because the advice is coming from a celebrity, it will get pop culture traction and could encourage the utilization of a test that has questionable value.  And, alas, we also know that a powerful narrative, like the one in Stiller’s blog, can overwhelm even a mountain of good clinical data.  Bottom line: not helpful.”

How much traction is this getting? The Today Show, with its audience of millions, has already had Dr. Mehmet Oz on the show discussing the piece and its implications. It was great to see the sometimes evidence-challenged Dr. Oz pouring some cold water on Stiller’s claims and citing U.S. Preventive Services Task Force data on the very modest benefits — and considerable harms — of PSA screening.

Caulfield gives Stiller points for engaging the controversy around PSA testing and referring to the relevant policy statements. However, I’d note that Stiller’s thesis appears to reflect the views of his urologist, Dr. Edward Schaeffer, who’s helped promote fear-mongering messages about “skyrocketing” rates of prostate cancer due to reduced PSA testing. Those statements aren’t based on sound science as I pointed out in a post a few months ago.

Skewed statistics can certainly stir up fear that would lead to blog posts about the need for more PSA testing. But such posts telling personal stories are no substitute for a comprehensive assessment of the evidence. The choice that was right for Stiller is not right for everyone.

“Frankly, I am sick of celebrities telling anecdotes about cancer screening,” says Prasad.  “Screening is too important to too many people, and has too broad public health repercussions.”

Prasad adds: “When celebrities choose to volunteer some, but not all, of their health information they may affect health decisions for many Americans (as was seen with Angelina Jolie). As such, celebrities have a responsibility to do so wisely. I am afraid Ben Stiller’s post does not meet this mark.”

Note: Please see the comments section for additional commentary from Dr. Prasad that was edited from the post for length.

Comments (38)

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Kevin Lomangino

October 5, 2016 at 11:36 amThe following comment is from Vinay Prasad, MD, MPH, whom I interviewed via email for the main post above. I edited these comments from the post to improve readability, but I think the point is worth sharing.

Ben Stiller says “I was lucky enough to have a doctor who gave me what they call a “baseline” PSA test when I was about 46.” He notes this runs counter to the USPSTF and even the ACS. Ben Stiller says everyone over 40 should get a PSA, but why does he discriminate against 39 year olds? If you accept Ben Stiller’s logic, that we should do anything to find cancer early (with near total disregard for net effects, harms or overdiagnosis), why is 40 Ben Stiller’s cutoff? He criticizes the American Cancer Society for 50, and yet equally arbitrarily chooses 40. If Ben Stiller thinks a 40 year old should be offered a PSA, why not a 39 year old? Why not every man? Since Ben Stiller does not employ careful scientific reasoning to reach his position, I would argue that Ben Stiller is logically inconsistent.

If he believes we should do everything possible to prevent advanced prostate cancer (and that seems his position), the test should be offered to any man of any age. Also, if Ben Stiller was to push his own thinking, he would argue that a prophylactic prostatectomy should be offered to any informed man. After all, PSA screening misses some prostate cancer– he conceeds that. Why should a healthy person not be allowed to remove their prostate beforehand? Since prostate cancer accounts for 2-3% of all deaths, the number needed to treat would be 33-50, and not that dissimilar from the most optimistic estimates of the PSA from the European randomized trial. Actually, Ben Stiller–since he thinks cutting out cancer early is the main priority and does not seriously weigh harms and overdiagnosis– should support the prophylactic removal of all un-essential organs, as any may become cancerous.

The purpose of this thought experiment is to illustrate the absurdity with Ben Stiller’s position: a slight more aggressive, slightly less evidence based recommendation the ACS. He is surely entitled to his opinion, but unfortunately his celebrity status will give that opinion disproportionate influence.

Illustrations from “The Decision” with explanations on Flickr. Over 7,000 views and not a bad starting point for the newly diagnosed prostate cancer patient.

Doctors will often draw on the bed sheet, their scrubs or on the exam table paper simplistic illustrations to help patients understand a concept. I have used the above illustrations hundreds of times over my thirty year career as a urologist for this very purpose. Click on the above link and see if they are beneficial to you-either by helping you understand an aspect of prostate cancer or better yet prompt a question for your doctor.

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A little knowledge is a "mighty" dangerous thing.

Title Views
When is a prostate nodule a nodule and do nodules always mean prostate cancer? More stats 96
the dreaded prostate biopsy revealed More stats 75
Home page / Archives More stats 66
Can you get cancer from having sex with a man who has prostate cancer?…Part Two-response to a comment. More stats 55
holy bloody mess batman!….the bleeding scrotum capo…i mean caper…tmi? More stats 53
“But I had radiation for my prostate cancer over 5 years ago!” Blood and clots in the urine after radiation for prostate cancer. More stats 31
Flooding around my catheter, blood around my catheter after a radical prostatectomy for prostate cancer More stats 21
If an elevated PSA goes down after antibiotics does that mean you don’t have prostate cancer? More stats 19
Wives/partners More stats 16
My bladder spasm experience More stats 13
high psa and normal prostate biopsy-what does that mean? well that you don’t have prostate cancer…maybe. More stats 10
watch out dr oz and live rectal exams…live prostate biopsies on patients doing impersonations. Which do you like the best? Please comment. More stats 8
Prostate cancer question for Prostate Diaries: Can you have sex the morning of a prostate biopsy? More stats 8
Reed’s prostate cancer journey process More stats 8
What should I expect after a prostate biopsy checking for prostate cancer because of an elevated PSA? More stats 7
Is the Madajet injector better than using a needle in No Scalpel vasectomies? More stats 6
Dr. Jo-An’s Sexuality Survey More stats 6
My biopsy experience More stats 5
Question: Urine leaks around catheter after prostatectomy. Is this normal? More stats 5
Did Vince Flynn die of prostate cancer because of too little screening or too much? Hmmmmmmmmmmmmmmm? More stats 5
Prostate cancer diagnosed too late to cure…how can this be? More stats 5
The significance of the Gleason’s Score and why we “CAN” tell the difference between the slow growing and the bad kind in prostate cancer. The dirty little secret? You have to do the biopsy to know. More stats 5
The anatomy of the prostate- “Water and Nerves” More stats 4
Why do men leak urine after having the prostate removed for prostate cancer? More stats 4