Archive for March, 2019

Man Boobs (“Gynecomastia”): What You Need to Know

March 30, 2019

Andrew Siegel MD  3/30/19

In females, the breasts (mammary glands) contribute to the alluring female form and allow ready access for the hungry infant, oddly an erogenous zone as well as a feeding zone. 

Breast_anatomy_normal_scheme

1. chest wall  2. pectoral muscles  3. glandular tissue (lobules)  4. nipple  5. areola  6. ducts  7. fatty tissue  8. skin

Image above: by Original author: Patrick J. Lynch. Reworked by Morgoth666 to add numbered legend arrows. – Patrick J. Lynch, medical illustrator, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=2676813  

But men, too, have breasts, areolas and nipples, yet male breasts lack glandular tissue (lobules) and have ducts that are blind-ending and incapable of lactation and providing nutrition to the infant.  This begs the question of why men even have breasts in the first place.  Furthermore, as desirable to the female form as breasts are, enlarged male breasts are viewed by most as unsightly and unattractive. 

So why do men have breasts?

Both genders start out initially as female.  In the absence of the male hormone testosterone (T), the fetus remains female (the default human model), and only in the presence of T does the fetus develops into a male.  However, breasts, areolas and nipples in their rudimentary form are present before T shapes cells into male organs. So, men have breasts, areolas and nipples because they were already present before maleness set in. Consider them nature’s evolutionary bonus!

What are sex hormones?

The main male sex hormone is T and the main female sex hormone estrogen (E).  However, males have some E and females have some T. T takes on two pathways in the body: Much of T is converted to dihydrotestosterone (DHT), the more potent and activated form. Some T is converted to E by virtue of the enzyme aromatase.

What are man boobs?

Man boobs—a.k.a. gynecomastia in medical speak—are a benign proliferation of glandular breast tissue. Gynecomastia is the most common breast condition in men. True gynecomastia—several centimeters or more of dense, firm, rubbery glandular tissue surrounding the areola—is distinguished from pseudo-gynecomastia, in which breast enlargement occurs due to fat deposition, without the presence of glandular tissue. Gynecomastia most commonly involves both breasts, although on occasion it can occur on just one side.

Under what circumstances do man breasts, which are supposed to be rudimentary and undeveloped, grow substantially?

Gynecomastia is seen in three distinct populations: newborns, adolescents and adults.  Breast tissue proliferation is present in the vast majority of newborns because of residual maternal female hormone E in the body, which is depleted in a matter of a few weeks, making the situation self-limited.  Gynecomastia is also seen during puberty in about 50% of adolescent boys, due to a delayed T surge relative to E activity, with spontaneous resolution in most.  However, at this sensitive age, the presence of man boobs on prominent display in the middle-school locker room negatively impacts self-image and self-esteem and can be devastating psychologically and emotionally.  The third population that develops man boobs is aging men, present to some extent in more than 50% after age 50, typically due to weight gain, decreased T levels, increased E levels, and altered T/E ratios.

Adolescent_with_Gynecomastia

Adolescent gynecomastia

Image above: David Andrew Copeland, Dr. Mordcai Blau http://www.gynecomastia-md.com [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0/)]

It is vital to make sure that male breast enlargement is not due to male breast cancer, which can occur on rare occasions. Cancer most often causes a hard mass within the breast tissue of one breast, sometimes with skin dimpling, and at times, lymph node enlargement –as opposed to gynecomastia that causes none of the aforementioned signs.

How is the extent of gynecomastia graded?

Grade I: minimal breast growth without drooping (ptosis in medical speak)

Grade II: moderate growth without drooping

Grade III: severe enlargement with drooping

Grade IV: severe enlargement with significant drooping

What is the main factor that underlies male breast growth? 

In both sexes, the main driving factor for breast development is hormonal—E activity and the ratio between E and T.  This explains normal female breast development at puberty (surge of E) as well as newborn, adolescent, and senior gynecomastia, which are associated with increased levels of E and altered ratio of E/T.

What medical issues give rise to gynecomastia?

There are 4 scenarios that can cause gynecomastia: conditions that cause excess E; conditions that cause low T; chronic medical conditions; and certain medications.

Thyroid disorders, e.g., hyperthyroidism, often increase sex hormone binding globulin (SHBG)—the protein that binds T and E—altering E/T ratio (since T is bound tighter than E), often giving rise to breast enlargement.  Certain tumors of the testes (Leydig, Sertoli cell and occasionally germ cell tumors that secrete human chorionic gonadotropin [HCG]) as well as some adrenal tumors can cause gynecomastia.  Carrying excessive weight and fat – particularly visceral abdominal fat (“beer belly”) – is a major risk factor for gynecomastia, as visceral fat contains an abundance of hormones including  aromatase, the enzyme that converts T to E. Men with large bellies consequently are often found to have low T and high E that can result in “emasculation,” with loss of sex drive, diminished erections, loss of penile length and the presence of man boobs.

Central_Obesity_008

Gynecomastia due to central obesity

Attribution: commons.wikimedia.org/wiki/File:Central_Obesity_008.jpg

Dysfunction of the testes, hypothalamus and pituitary can give rise to low T and promote gynecomastia.

Chronic medical conditions—including kidney disease and cirrhosis—often cause gynecomastia along with many other symptoms.

Numerous medications may give rise to male breast enlargement: HCG, estrogens, human growth hormone, anabolic steroids, finasteride and dutasteride, androgen deprivation therapy medications, spironolactone, cimetidine, proton pump inhibitors, digoxin, verapamil, alcohol, and opioids.

How is gynecomastia evaluated?

Visual inspection is used to determine the extent of enlargement and drooping and physical examination to ensure the absence of an underlying breast mass. It is important to do laboratory testing, including liver, kidney and thyroid function tests as well as total T, free T, SHBG, E, luteinizing hormone (LH), prolactin, HCG.

How is gynecomastia treated?

If a specific underlying medical condition or hormonal abnormality is identified, it needs to be addressed. If the gynecomastia is drug induced, the culprit medication needs to be stopped. If due to obesity, commonsense solutions are weight loss and exercise.

The goal of medical therapy is to modulate the E/T ratio and this can be done with the use of medications including clomiphene (selective estrogen receptor modulator—SERM); tamoxifen (SERM plus blocks action of E on breast tissue); danazol (androgen receptor agonist); anastrozole (aromatase enzyme inhibitor), depending on the specific circumstance.

At times, surgery may be the only solution for gynecomastia. In general, liposuction of excessive fatty and glandular tissue is used successfully for mild-moderate gynecomastia whereas liposuction with excision of excessive skin or surgical excision (reduction mammoplasty) is used for severe gynecomastia with drooping.

GynecomastiaFrontalAsymSevere

Before and after surgical treatment

Attribution of image above: JMZ1122 Dr. Mordcai Blau http://www.gynecomastia-md.com [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

Dr. Siegel’s newest book: PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Preview of Prostate Cancer 20/20

Video trailer for Prostate Cancer 20/20

Dr. Siegel is the author of 4 other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

 

 

 

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Her Breasts and His Prostate: So Different, Yet So Similar!

March 23, 2019

Andrew Siegel MD   3/23/2019

Gender_differences_male_female

Thank you Wikipedia for image above

One would think that the mammary glands and prostate gland are worlds apart—separated by gender, geographical locale on the body, external vs. internal—but in reality, they have many more similarities than differences.

The female breasts and the male prostate are both sources of fascination, curiosity, and fear.  Surprisingly, they have much in common.  The breasts—with an aura of mystique and power—are situated in the chest superficial to the pectorals, contributing to the alluring female form and allowing ready access for the hungry infant, oddly an erogenous zone as well as a feeding zone. On the other hand, hidden deep in the pelvis at the crossroads of the male urinary and reproductive systems, the prostate is arguably man’s center of gravity.

The breasts and prostate both serve important “nutritional” roles. Each function to manufacture a milky white fluid; in the case of the breasts, the milk serving as nourishment for infants, and in the case of the prostate, the “milk” serving as sustenance for sperm cells.

Breasts are composed of glandular tissue that produces milk and ducts that transport the milk to the nipple. The remainder of the breast consists of fatty tissue.  The glandular tissue is sustained by the sex hormone estrogen and after menopause, when estrogen levels decline, the glandular tissue withers, with the fatty tissue predominating.

The prostate is made up of glandular tissue that produces prostate “milk” and ducts that empty into the urethra. At the time of ejaculation, the prostate fluid mixes with other reproductive secretions and sperm to form semen. The remainder of the prostate consists of fibro-muscular tissue. The glandular tissue is sustained by the sex hormone testosterone and after age 40 there is a slow and gradual increase in the size of the prostate gland because of glandular and fibro-muscular cell growth.

Access to the breasts as mammary feeding zones is via stimulation of the erect nipples through the act of nursing.  Access to prostate fluid is via stimulation of the erect penis, with the release of semen and its prostate fluid component at the time of ejaculation.

The breasts and prostate can be considered reproductive organs since they are vital to the nourishment of infants and sperm, respectively. At the same time, they are sexual organs. The breasts have a dual role that not only provide milk to infants, but also function as erogenous zones that attract the interest of the opposite sex and contribute positively to the sexual and thus, reproductive process.  Similarly, the prostate is both a reproductive and sexual organ, since sexual stimulation resulting in ejaculation is the means of accessing the prostate’s reproductive function.

Both breast and prostate are susceptible to similar disease processes including infection, inflammation and cancer. Congestion of the breast and prostate glands can result in a painful mastitis and prostatitis, respectively.  Excluding skin cancer, breast cancer is the most common cancer in women and prostate cancer is the most common cancer in men. Breast and prostate tissue are dependent upon the sex hormones estrogen and testosterone, respectively, and one mode of treatment for both breast cancer and prostate cancer is suppression of these hormones with medications. Both breast and prostate cancer incidence increase with aging. The median age of breast cancer at diagnosis is the early 60s and breast cancer is the second most common form of cancer death, after lung cancer. There are about 3 million breast cancer survivors in the USA. The median age of prostate cancer at diagnosis is the mid-late 60s and prostate cancer is the second most common form of cancer death, after lung cancer. There are about 3 million prostate cancer survivors in the USA.

Both breast and prostate cancer are often detected during screening examinations before symptoms have developed. Breast cancer is often picked up via screening mammography, whereas prostate cancer is often identified via an elevated or accelerated PSA blood test.  Alternatively, breast and prostate cancer are detected when an abnormal lump is found on breast exam or digital rectal exam of the prostate, respectively.

Both breast and prostate cells may develop a non-invasive form of cancer known as carcinoma-in-situ—ductal carcinoma-in-situ (DCIS) and high-grade prostate intraepithelial neoplasia (HGPIN), respectively—non-invasive forms in which the abnormal cells have not grown beyond the layer of cells where they originated, often predating invasive cancer by years.

Family history is relevant to both breast and prostate cancer since there can be a genetic predisposition to both types and having a first degree relative with the disease will typically increase one’s risk.  Both women and men can inherit abnormal BRCA1 and BRCA2 tumor suppressor genes. Women who inherit BRCA1 and BRCA2 abnormal genes have about a 60% and 45% chance of developing breast cancer by age 70, respectively.  Men who inherit the BRCA1 abnormal gene have a slightly increased risk for prostate cancer; men who inherit the BRCA2 abnormal gene have about a seven-fold increased risk. BRCA1 mutations double the risk of metastatic prostate cancer and BRCA2 mutations increase the risk of metastatic prostate cancer by 4-6 times, with earlier onset and higher grade at diagnosis.

Imaging tests used in the diagnosis and evaluation of both breast and prostate cancers are similar with ultrasonography and MRI commonly used. Treatment modalities for both breast and prostate cancer share much in common with important roles for surgery, radiation, chemotherapy and hormone therapy.

 

….On the subjects of breasts, next week’s entry will cover “When men develop breasts.”

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Preview of Prostate Cancer 20/20

Video trailer for Prostate Cancer 20/20

Dr. Siegel is the author of 4 other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

 

 

 

Small Muscles With Big Impact: Insights Into PC Muscle Training

March 16, 2019

Andrew Siegel MD  3/16/19

Today’s entry provides insights into “the little muscles that could” and the wherewithal to get these muscles into tip-top form, providing benefits from the bedroom to the bathroom. 

Let us start with two superb 2-minute Australian 3D animated videos that provide superb information about the pelvic floor muscles in each gender (and the accent is a treat to your ears):

Female video

Male video

Pelvic floor muscle training provides a workout of the all-important PC –pubococcygeus muscle (see image below of PC and perineal muscles in males on left and females on right).  In many contexts, PC stands for “politically correct.” The PC is certainly not a “politically correct” muscle, being a muscle of the nether regions that has a vital role in sexual, urinary and bowel function.

 

1116_Muscle_of_the_Perineum

Attribution: URL: https://cnx.org/contents/FPtK1zmh@8.108:b3YG6PIp@6/Axial-Muscles-of-the-Abdominal
Version 8.25 from the Textbook
OpenStax Anatomy and Physiology
Published May 18, 2016

The PC may not be politically correct like the exposed “glamour” muscles—e.g., the biceps, triceps and pectorals—those external, seen and for-show muscles, often worked out more for form than function.  However, the PC muscle is the small muscle that needs a big introduction because, although unexposed and behind the scenes, it is truly a muscle of “go,” all function vs. form, without which you would be living in adult diapers.  Not only does the PC contribute significantly to bladder and bowel control, but it also has a vital role in both genders in terms of sexual function, specifically the ability to obtain an erection (penile and clitoral) and achieve orgasm.

Pelvic health has always been a somewhat neglected focus of both women’s and men’s health. Pelvic floor problems are incredibly common in women following the trauma of childbirth, often resulting in anatomical changes that can cause stress urinary incontinence, pelvic organ prolapse and sexual dysfunction. In men, the aging process, pelvic surgery and pelvic muscle weakness can contribute to post-void dribbling, stress urinary incontinence and erectile/ejaculatory dysfunction.  A strong pelvic floor helps prepare the female body for pregnancy, labor and delivery and in both genders can improve/prevent urinary, bowel and sexual issues.

There are several challenges in motivating one to exercise a muscle that is internal and not visible.  One major challenge is ensuring that the proper muscles are being exercised, since very often those who think they are contracting their PC muscle are, in fact, contracting their butt, thigh or abdominal muscles.  Another challenge is making the exercise regimen interesting so that the routine is not given up prematurely out of boredom. If these challenges can be surmounted, the ultimate goal of PC training is to learn how to integrate the exercises into situations that arise in everyday life in order to improve pelvic function and quality of life, what I call “Kegels-on-demand.”

I have written two books on pelvic health, one for gentlemen and one for the ladies.  In addition to the two books, I co-created the comprehensive, interactive, FDA-registered PelvicRx pelvic floor muscle training programs designed for both genders, built upon the foundational work of renowned Dr. Arnold Kegel. These programs empower participants to increase their pelvic floor muscle strength, tone, and endurance, helping to improve/prevent urinary, bowel and sexual issues.

Male PelvicRx unveils the powers of the mysterious male pelvic floor muscles and how to harness their potential through a simple, home-based, follow-along pelvic exercise program. It is a well-designed, easy to use, interactive 4-week pelvic training DVD that will optimize the strength and endurance of the pelvic floor exercises. It provides education, guidance, training, and feedback to confirm the engagement of the proper muscles. It is structured so that repetitions, contraction intensity and contraction duration are gradually increased over the course of the program. This progression is the key to maximizing pelvic strength and endurance in order to address urinary as well as sexual issues.

home_main_01

The video is intended to complement to the book: MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health.

MPF cover 9.54.08 AM

 

Female PelvicRx pelvic training video unveils the powers of the female pelvic floor muscles and how to harness their potential through a simple, home-based, follow-along pelvic exercise program to help optimize the strength and endurance of the pelvic floor muscles.

The video is intended to complement the book: THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health.  The book provides specific programs for each specific pelvic floor issue: stress incontinence; overactive bladder; pelvic organ prolapse; sexual issues; bowel issues; and pelvic pain.

Cover

 

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Preview of Prostate Cancer 20/20

Video trailer for Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Andrew Siegel MD Apple iBooks author page

Prostate Cancer: We’ve Come A Long Way

March 9, 2019

Andrew Siegel MD   3/9/19

new-year-2019-happy-new-year-start-success-path-1449049-pxhere.com

Thank you PxHere, for image above

The Friday, June 18, 1993 Bergen Record (Bergen County New Jersey newspaper) published a letter to the editor that I wrote in response to an article entitled “Hazards of Waiting to Treat Prostate Cancer”:

I take issue with the article, “Prostate Cancer: Difficult Choices” (June 5, 1993), summarizing the Journal of the American Medical Association Report, which concluded that surgery or radiation, provides minimal, if any, benefits compared with watchful waiting.

Not all prostate cancer is the same. Cancer of the prostate can behave in an indolent fashion (very slow-growing), in which case a man will die WITH prostate cancer, but not OF prostate cancer.  But prostate cancer can also be aggressive, resulting in rapid progression and death: 35,000 deaths per year in American men. 

For the most indolent of prostate cancers, intervention will rarely alter the excellent prognosis. For the most aggressive of cancers, intervention will rarely alter the poor prognosis. However, in the gray zone between these two extremes exists a substantial population for which intervention will literally spell the difference between life and death. If physicians could accurately predict tumor behavior and potential for progression, we could more accurately choose between surgery, radiation, or watchful waiting. Unfortunately, despite great technical strides, we do NOT currently possess such a means.

Until the means and sophistication to accurately predict the behavior of individual prostate cancer becomes available, it behooves us as urologists to offer aggressive therapy to most men with this disease; otherwise, “watchful waiting” might translate into watch the cancer and wait for progression and death.

Andrew Siegel MD, River Edge, New Jersey, Assistant Clinical Professor of Urology at University of Medicine and Dentistry of New Jersey

Twenty-five years later times have certainly changed!  No longer are all prostate cancers lumped together with the thought that they are one and the same and are best served by surgical removal. What has not changed is the variability of prostate cancer behavior: some are so unaggressive that no cure is necessary, others are so aggressive that no treatment is curative, and many are in between these two extremes–moderately aggressive and curable. A major advance in the last few decades is the vast improvement in the ability to predict which prostate cancers need to be actively treated and which can be watched, a nuanced and individualized approach.

Prostate cancer can be described through an analogy using birds, rabbits and turtles in a barnyard, the animals representing prostate cancers with different degrees of aggressiveness and the barnyard representing the prostate. The goal is early detection and not allowing the animals to escape the barnyard (and cause a cancer death). The birds can easily fly away, designating the most aggressive cancers, those that have often spread by the time they are detected and are often not amenable to cure. On the other hand, the turtles crawl very slowly, exemplifying non-lethal, low risk cancers that can often be managed with active surveillance. The rabbits are the intermediate group that can hop out at any time, illustrating potentially lethal cancers that would likely benefit from treatment, those cancers that can be cured.

The following editorial comment with reference to an article on treatment stratification based upon risk (published in the February 2018 Journal of Urology) sums up current trends in prostate cancer management:

Low risk patients do not benefit from radical therapy unless perhaps they are exceedingly young.  Intermediate risk patients die of prostate cancer and benefit from treatment.  High risk patients must be selected carefully for treatment, as many will not benefit given the risk of occult metastatic disease.  Most importantly, men have to live long enough to benefit from treatment for treatment to be undertaken.  In practice that is the hardest thing to figure out.  In many regards, this study is reassuring in that it supports the current trends in urological oncology, i.e., surveillance for low risk patients, early intervention for intermediate risk cancers in young patients and strides towards multimodal therapy to improve outcomes in patients with high risk disease.

Dr. Samir Taneja, Professor of Urological Oncology, NYU Langone Medical Center

The following are the sage words of Dr. Willet Whitmore from 1973. He served as chief of urology at what is now Memorial Sloan-Kettering Cancer Center (and died in 1995 of prostate cancer):

Appropriate treatment implies that therapy be applied neither to those patients for whom it is unnecessary nor to those for whom it will prove ineffective. Furthermore, the therapy should be that which will most assuredly permit the individual a qualitatively and quantitatively normal life. It need not necessarily involve an effort at cancer cure. Human nature in physicians, be they surgeons, radiotherapists, or medical oncologists, is apt to attribute good results following treatment to such treatment and bad results to the cancer, ignoring what is sometimes the equally plausible possibility that the good results are as much a consequence of the natural history of the tumor as are the bad results.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Preview of Prostate Cancer 20/20

Video trailer for Prostate Cancer 20/20

Dr. Siegel is the author of 4 other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Prostate Cancer: Facts, Risk Factors and Detection

March 2, 2019

Andrew Siegel MD   3/2/19

A doctor-turned-patient friend of mine who also happens to be a medical school professor stated it clearly: “As patients we often forget what we want to ask and forget what we were told.”

One of my missions is to “bridge the gap” that exists between the medical community and the non-medical layperson.  This gap is best bridged by providing the education to complement and supplement the office visit, aspiring to answer the questions that were not asked and reinforce the answers to the questions that were asked, enabling informed decisions–after all, the word “doctor” stems from the Latin “docere,” meaning teacher: “The best prescription is knowledge.”

cancerAttribution of image above: Alpha Stock Images – http://alphastockimages.com/

Facts and epidemiology

Prostate cancer is the most common malignancy — aside from skin cancer — among men in most western populations, with an estimated 165,000 new cases in 2018 in the United States. It is the second leading cause of cancer death, with an estimated 30,000 deaths in 2018 (lung cancer is the leading cause). To put this in perspective, heart disease claims more than 600,000 lives per year in American men and is the leading cause of death in men with prostate cancer.  Even in the population of men with prostate cancer, many more men die with it than of it. In fact, there are almost 3 million prostate cancer survivors in the U.S.

Fact: In New Jersey it is estimated that in 2018 there were 5430 new cases of prostate cancer and 750 deaths.

Prostate cancer is unique among tumors in that it exists in two forms: latent (evident on autopsy studies, but not causing an abnormal rectal exam or PSA (prostate specific antigen blood test), present in 60-70% of men older than 80; and clinically evident (causing an abnormal rectal exam and/or elevated PSA), affecting about 1 in 9 men in the U.S. Overall, men have a roughly 11% chance of being diagnosed with prostate cancer and a 3% chance of dying from it. This high ratio of prostate cancer occurrence rate to death rate suggests that many of these cancers do not threaten one’s life and are “indolent” cancers.

Risk factors

The major risk factors for prostate cancer are age, race, family history, and lifestyle. The likelihood of developing prostate cancer increases with aging—the greatest risk factor for prostate cancer—thought to be due to accumulation of DNA mutations from oxidative damage (literally “rusting”) of prostate cells. With each decade of aging, the occurrence of prostate cancer increases considerably. More that 60% of men are 65 years old or older at the time of diagnosis, with average age at diagnosis in the late 60s.

African American men have the highest incidence of prostate cancer,1.6 times that of Caucasian men in the U.S.; furthermore, the death rate for African American men is 2.4 times higher than that of Caucasian men. On a worldwide basis, the greatest occurrence of prostate cancer is in North America and Scandinavia and the lowest in Asia. Prostate cancer is approximately 8 times more prevalent in Western countries than it is in Eastern countries.

Prostate cancer tends to run in families, so it is vital that male children of prostate cancer patients get checked annually starting at age 40 with a PSA blood test and a digital rectal exam of the prostate. (It is my belief that all men should receive an initial baseline PSA and digital rectal exam at age 40.)  Risk increases according to the number of affected family members (the more affected, the higher the risk), their degree of relatedness (brother and/or father affected confer a higher risk than cousin and/or uncle) and the age at which they were diagnosed (relatives of patients diagnosed younger than 55 years old are at highest risk). If you have a brother or a father with prostate cancer, your risk of developing it is doubled. If you have three family members with prostate cancer, or if the disease occurs in three generations in your family, or if two of your first-degree relatives have been diagnosed at an age younger than 55 years, you have a good likelihood for having hereditary prostate cancer, which confers a 50% risk of developing the disease.

My father, a retired urologist, was diagnosed with prostate cancer at age 65 and is currently 87 years old and thriving. I have been especially diligent in seeing my internist annually for a PSA blood test and a digital rectal exam of the prostate. Additionally, I have been proactive in taking finasteride to decrease my risk for prostate cancer.

An unhealthy lifestyle is an additional risk factor for prostate cancer.  Being overweight or obese and consuming a Western-style diet full of calorie-laden, nutritionally-empty selections (fast food, highly processed and refined foods, excessive sugars, etc.) puts one at greater risk for aggressive prostate cancer as well as dying from prostate cancer.  Asian men who reside in Asian countries have the lowest risk for prostate cancer; however, after migrating to Western countries, their risk increases substantially. This is highly suggestive that diet and other lifestyle factors play a strong role in the development of prostate cancer.

Detection

Most prostate cancers are detected by PSA screening. Widespread PSA blood testing has resulted in the increased diagnosis of early, asymptomatic prostate cancer with a reduction in the prostate cancer death rate.  This is as opposed to the pre-PSA era when most cancers were detected via an abnormal prostate exam or symptoms due to advanced prostate cancer.

Screening is of vital importance because localized prostate cancer typically causes no symptoms or warning signs whatsoever.  Prostate cancer is most commonly diagnosed by a biopsy prompted because of a PSA elevation, an accelerated increase in the PSA over time, or an abnormal digital rectal examination (a bump, lump, hardness, asymmetry, etc.). Those prostate cancers picked up via a PSA elevation or acceleration now account for 75% of all newly diagnosed prostate cancers.

The observed trends in PSA-driven detection of prostate cancer at earlier stages and declining death rates where screening is commonly used point to the benefits of screening. If prostate cancer is not actively sought, it is not going to be found. When prostate cancer does cause symptoms, it is generally a sign of locally advanced or advanced prostate cancer and therein lies the importance of screening. The downside of screening is over-detection of low risk prostate cancer that may never prove to be problematic but may result in unnecessary treatment with adverse consequences. The downside of not screening is the under-detection of aggressive prostate cancer, with adverse consequences from necessary treatment not being given.

Urologists’ challenge

The challenge for those of us who treat prostate cancer is to distinguish between clinically significant (“aggressive”) and clinically insignificant (“indolent”) disease and to decide the best means of treating clinically significant disease to maintain quantity and quality of life.

Natural history of prostate cancer

The good news is that when detected early, clinically significant prostate cancer is highly curable. However, such prostate cancers if left untreated have a slow, steady and predictable behavior with potential for local tumor progression and spread. Death from prostate cancer is unpleasant, often involving painful cancer spread to the spine and pelvis and not uncommonly kidney and bladder obstruction. Thus, early treatment is an important consideration for men with a life expectancy exceeding 10 years. When prostate cancer is treated, it is with the intent of avoiding the long-term consequences, i.e., that which might occur 10, 15 and 20 years down the line.  Even when prostate cancer is not discovered early, although not necessarily curable, it is most often a manageable condition.

Team approach

I embrace the concept of the multi-disciplinary health care team approach to prostate cancer. In addition to the urologist, the physicians who specialize in prostate cancer are the radiation oncologist and the medical oncologist. This trio may be considered the prostate cancer team and are a powerful combination in terms of their ability to educate and guide management. Each member of the team has a different expertise and skillset and contributes vitally to the decision-making and management process.

Not surprisingly, physicians have inherent biases directly related to their training. In general, the urological surgeon’s bias is towards favoring surgery, the radiation oncologist’s is radiation therapy and the medical oncologist’s is chemotherapy. I have made great efforts to get beyond my inherent surgical bias and to give honest and appropriate advice to my patients, based upon the “big picture.” I strongly believe that all physicians should practice the FBSU test (Father, Brother, Son, Uncle test)—giving their patients the same advice they would give to their own family members.

Wishing you the best of health,

2014-04-23 20:16:29

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health.  He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

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Preview of Prostate Cancer 20/20

Video trailer for Prostate Cancer 20/20

Dr. Siegel is the author of 4 other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks