Archive for the ‘health and wellness’ Category

Prostate Cancer Risk Assessment: A Sensible Guide To Appropriate Treatment

June 22, 2019

Andrew Siegel MD  6/22/19

To determine the most appropriate and effective prostate cancer management strategy, newly diagnosed patients are “risk stratified” to predict the cancer’s potential for aggressiveness and severity. Today’s entry explains the means of this process.

Each case of prostate cancer is unique and has a variable biological potential for progression, spread and death. Prostate cancer can be “triaged” into low, intermediate and high risk categories.  Many cancers are “indolent” (low risk) requiring no treatment aside from careful monitoring, while some at the other end of the spectrum are so highly aggressive (high risk) that they incur the prospect of metastatic disease and cannot be cured (but can be well managed), and many lie in the middle (intermediate risk), in which there is the potential for death from prostate cancer and benefit from treatment, which is often curative.

Classification of prostate cancer into risk categories is based upon the following factors: tumor stage, Gleason score, volume of cancer on biopsy, PSA and PSA density, and at times, genomic testing. Additional factors that influence treatment choices for prostate cancer are: age, life expectancy, health status, presence or absence of urinary symptoms and personal preferences.

The extent of prostate cancer—whether localized, regionally advanced or metastatic—is an important factor that informs treatment. Extent or “staging” is determined by digital rectal exam and magnetic resonance imaging; additionally, computerized tomography and bone scan are often obtained to stage unfavorable intermediate risk and higher risk prostate cancer.

Tumor staging

The TNM (Tumor/ Lymph Nodes/ Metastases) system is used to determine the stage of prostate cancer. T refers to tumor size; N the extent of lymph node involvement; and M to the presence or absence of metastasis (spread).

Prostate cancer diagnosed because of a PSA elevation without the presence of an abnormality on digital rectal examination (DRE) is a different tumor category than one diagnosed because of an abnormality on DRE. This is because the presence of palpable cancer (one that can be felt on DRE) indicates that the cancer is already close to the capsule—perhaps beyond the capsule—whereas non-palpable cancer is typically earlier in the natural course of cancer progression.

Stages Of Prostate Cancer

Stages of prostate cancer (Image from PROSTATE CANCER 20/20:  A Practical Guide To Understanding Management Options For Patients And Their Families)

Stage T1

Tumor is microscopic and confined to the prostate and not apparent on DRE. T1a is tumor found incidentally in prostate tissue removed because of symptomatic enlargement (< 5 % of prostate tissue removed); T1b is tumor found incidentally in prostate tissue removed because of symptomatic enlargement (> 5 % of prostate tissue removed); T1c is tumor identified by biopsy because of PSA elevation or acceleration.

Stage T2

Tumor is confined to the prostate and is detected by DRE.  T2a involves less than half of one side of the prostate; T2b involves more than half of one side; T2c involves both left and right sides of the prostate.

Stage T3 or T4

T3a tumors extend beyond the prostate capsule, sparing the seminal vesicles; T3b tumors invade the seminal vesicles. Stage T4 tumors have spread to organs near the prostate, but within the pelvis, e.g., bladder, rectum or pelvic sidewall.

Stage N+ or M+

Cancer has spread to pelvic lymph nodes (N+) or to lymph nodes, bones, and/or organs distant from the prostate (M+).

Gleason Score

Dr. Gleason devised a clever system that microscopically grades prostate cancer based upon cellular architecture. He recognized that prostate cancer grade is the most reliable indicator of the potential for cancer growth and spread. The grading system that bears his name provides one of the best guides to prognosis and treatment.

To determine Gleason score, the pathologist assigns a separate numerical grade to the two most predominant architectural patterns of the cancer cells, the first number representing the grade of the primary (most predominant) pattern and the second number representing the grade of the secondary pattern. The grades range from 3 (just over the threshold for cancer) to 5 (the cells that have the most cancerous appearance). The sum of the two grades is the Gleason score. The lowest possible score is 6; the highest is 10. The Gleason score predicts the aggressiveness and behavior of the cancer, with higher scores having a worse prognosis than lower scores.

Gleason score is one of the most important factors to be considered prior to making an informed treatment choice. Whereas men with low Gleason scores are often candidates for active surveillance, a high Gleason score mandates more aggressive management.

There are 5 Gleason Grade Groups based upon Gleason score:

Grade Group 1 (Gleason score 3+3=6)

Grade Group 2 (Gleason score 3+4=7)

Grade Group 3 (Gleason score 4+3=7)

Grade Group 4 (Gleason score 4+4=8 or 3+5=8 or 5+3=8)

Grade Group 5 (Gleason score 4+5=9 or 5+4= 9 or 5+5=10)

To help understand the significance of the Gleason score, the rates of undetectable PSA five years after surgical removal of the prostate in Grade Groups 1-5 are the following: 96%, 88%, 63%, 48%, and 26%, respectively.

Number cores with cancer

Generally, at least 12 biopsy cores are obtained and the number of cores that have cancer can provide invaluable information to help guide treatment. The more cores that contain cancer, the greater the volume of cancer and the greater the risk.  A man who has 12/12 cores with cancer has a very different disease than a man with 1/12 cores with cancer.

Percent tumor involvement (PTI)

The percentage of cancer in each cancer core is also useful information. In general, the greater the PTI, the greater the risk. A man with cancer in 3/12 cores that involves 100% of each core has a very different disease than a man with cancer in 3/12 cores that involves 5% of each core.

PSA and PSA velocity

PSA is a superb tumor marker for men with prostate cancer. In general, the lower the PSA, the greater the chance of localized (organ-confined) cancer and conversely, the higher the PSA, the greater the chance of non-localized cancer.  The lower the PSA, the greater the likelihood of cure with surgery or radiation therapy.  Men with a PSA higher than 20 have a greater risk of locally advanced or metastatic disease and a higher likelihood of failing surgery or radiation therapy.

PSA velocity (rate of change over time) also provides essential prognostic information. A high PSA velocity preceding the diagnosis of prostate cancer is associated with a poorer prognosis.

PSA density (PSAD)

PSAD is the relationship of PSA to the size of the prostate, determined by dividing PSA by the prostate volume. The volume of the prostate is easily determined by ultrasound or by MRI (magnetic resonance imaging). A PSA density > 0.15 is considered to be a higher risk.

Genomic testing

Genomic biomarkers have become an increasingly popular tool for risk stratification. Oncotype DX (genomic prostate score) is one such assay that determines the expression of 17 genes. It is often used for newly diagnosed Gleason 6 (3+3) and 7 (3+4) cancers to help determine who will benefit from active surveillance vs. surgery or radiation.

Age and life expectancy

The prevailing view accepted among prostate cancer experts is that the more years one has left to live, the greater the likelihood that surgery will provide the greatest chance of achieving that potential. So, if you are 43 years old and in perfect health, the most prudent option is often a radical prostatectomy. On the other hand, if you are elderly and have a less than ten-year life expectancy, you likely will not need any treatment as other more pressing medical issues may cause your demise before the prostate cancer has a chance to.

With respect to age, I refer to “physiological” age as opposed to “chronological age.”  In other words, not how many years per se that you have lived on the planet, but at what age you are functioning and how many years you may be expected to live.  Of two men who are chronologically 65 years old, one may be functioning like a 55-year-old and the other as an 80-year-old, and treatment needs to be tailored accordingly.

As surgery and radiation have competitive 15-year results and the demands and potential side effects of surgery are greater than that of radiation, at a certain age, radiotherapy becomes a more prudent consideration.

Health status

If you are not in good health and do not have an expected ten-year life expectancy, there is usually no compelling reason to treat the prostate cancer as other health issues are likely to be of more concern than the prostate cancer.

In general, surgery should be reserved for healthy men who can tolerate an invasive surgical procedure and the general anesthesia necessary to undergo it. If your health is compromised, but you have a greater than ten-year life expectancy, radiation becomes a sensible management option.

Urinary symptoms

Benign prostate enlargement commonly accompanies aging, paralleling the increasing prevalence of prostate cancer with aging. As the prostate enlarges, it often—but not always—squeezes the urethral channel, making urination difficult and resulting in annoying symptoms and sleep disturbance.  An enlarged prostate can act like a hand squeezing a garden hose, compromising the flow through the hose. The situation can be anything from a tolerable nuisance to one that has a huge impact on one’s daily activities and quality of life.

The presence of Lower Urinary Tract Symptoms (LUTS) can be an important factor in guiding treatment options.

 Obstructive LUTS consist of the following:

hesitancy—a stream that is slow to start

weak stream—a stream that lacks force

narrow stream—a thin stream

intermittency—a stream that starts and stops

straining—the need to use abdominal muscles to urinate

prolonged emptying time—excessive time to empty the bladder

incomplete emptying—inability to empty the bladder

Irritative LUTS consist of the following:

frequency—urinating more often than normal

nocturia—awakening from sleep to urinate

urgency—the sudden and strong desire to urinate

precipitancy—the need to get to the toilet in a hurry

urgency incontinence—the sudden and strong desire to urinate with the inability to get to the toilet in time to prevent leakage

The presence or absence of LUTS can be an important factor to help guide the most appropriate treatment options. For example, if a man diagnosed with prostate cancer has significant LUTS, a prostatectomy may be the best management option to treat both the cancer and the annoying symptoms, as opposed to radiation therapy that can worsen the LUTS.

Personal preferences

Our intention as urologists is not to dictate exactly what approach to take, as there are usually several competing management options, but to provide education, direction and guidance through the options, offering sensible and pragmatic advice based upon our knowledge and experience.

I truly believe in the FBSU test (Father, Brother, Son, Uncle test)— giving patients the same advice I would give to family members. Every man has different circumstances, priorities, medical issues, life expectancies and concerns about the side effects of treatment alternatives.  Recognizing this, the opinions of the patient, family members and loved ones who have a clear understanding of the management options are of paramount importance in the ultimate choice of a treatment.  The goal of this collaborative and shared decision-making process between patient and physician is to optimize medical decisions by helping patients choose the option they feel most comfortable with.

RISK CATEGORIZATION (This strategy is based upon the National Comprehensive Cancer Network guidelines)

Integrating the factors of tumor stage, Gleason score, cancer volume, PSA and PSA density, supplemented with genomic testing, an individual case of prostate cancer can be assigned to one of five risk categories ranging from very low risk to very high risk. This risk categorization is helpful in predicting the future behavior of the prostate cancer and in the management decision-making process.

The following are the five risk groups and the criteria for membership in each:

Very Low Risk: T1-T2a; Gleason score 6; fewer than 3 cores with cancer; PTI less than 50% of cancer in each core; PSA < 10; PSA density < 0.15

Low Risk: T1-T2a; Gleason score 6; more than 3 cores with cancer; PTI greater than 50% of cancer in any core; PSA < 10

Intermediate Risk: T2b-T2c or Gleason score 7 or PSA 10-20

Within the intermediate risk category, further sub-stratification is as follows:

      Favorable Intermediate Risk:

T1-T2a, Gleason score 6, PSA 10-20

T1-T2a, Gleason score 7 (3+4), PSA < 10

      Unfavorable Intermediate Risk:

T2b, Gleason score 7 (3+4), PSA < 10

T1-T2, Gleason score 7 (3+4), PSA 10-20

T1-T2, Gleason score 7 (4+3), PSA < 20

High Risk: T3a or Gleason score 8-10 or PSA > 20

Very High Risk: T3b-T4 or Gleason grade 5 as the predominant grade (the first of the two Gleason grades in the Gleason score) or > 4 cores Gleason score 8-10

Coming next week…An overview of prostate cancer treatment options based upon risk assessment.

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

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s 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

 

 

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Making Sense of the Gleason Prostate Cancer Grading System

June 15, 2019

Andrew Siegel MD  6/15/19

Each case of prostate cancer is unique and has a distinctive biological behavior.  One of the best predictors of the future behavior of any prostate cancer is the  cancer grade, a microscopic determination made by the examining pathologist.  Dr. Donald Gleason, a former chief of pathology at the Minneapolis Veterans Administration Center, devised a prostate cancer grading system many years ago that is still used today. His legacy, the system that bears his name—the Gleason score—provides one of the best and most reliable predictors for prostate cancer growth and spread.  Gleason score remains one of the most important factors guiding the individualized and nuanced treatment of the prostate cancer.

Gleason grade, Gleason score, Gleason grade group

Gleason GRADE

Gleason grade is determined by the pathologist who studies the biopsied prostate cancer with a microscope. Grade is indicative of the extent of difference in the cellular architecture of cancer cells as compared with normal cells. Low grade cancers appear almost like normal cells whereas high grade cancers bear little resemblance to normal cells. Gleason grades range from 3 (just over the threshold for cancer) to 5 (the cells that have the most cancerous appearance). Grade 3 is considered a low grade and grade 5 a high grade cancer.

Gleason

Gleason grades based upon cellular architecture: note that grades 1 and 2 are not considered to be cancer.  Thank you AUAnet.org

Gleason SCORE

The cancer from any individual biopsy site is often heterogeneous as opposed to homogeneous. In other words, cancer cells often have a variety of architectural patterns,  a predominant pattern as well as secondary and tertiary patterns. To determine Gleason score, the pathologist assigns a separate numerical grade to the two most predominant architectural patterns of the cancer cells, the first number representing the grade of the primary (most predominant) pattern and the second number representing the grade of the secondary pattern. The sum of the two grades is the Gleason score. The lowest possible score is 6; the highest is 10.

Gleason score predicts the aggressiveness and behavior of the cancer. Higher scores indicate a worse prognosis than lower scores because the more mutated cells typically grow faster than the more normal-appearing ones. Prognosis also depends on further refinements. For example, a Gleason score of 7 can occur two ways: “4+3” or “3+4”. With “4+3,” cancer cells in the most predominant category appear more aggressive than those in the secondary pattern, suggesting a more serious threat than a “3+4” score, in which cells in the most predominant group appear less aggressive.

Gleason GRADE GROUP

There are 5 Gleason grade groups based upon Gleason score:

Grade Group 1 (Gleason score 3+3=6)

Grade Group 2 (Gleason score 3+4=7)

Grade Group 3 (Gleason score 4+3=7)

Grade Group 4 (Gleason score 4+4=8 or 3+5=8 or 5+3= 8)

Grade Group 5 (Gleason score 4+5=9 or 5+4= 9 or 5+5=10)

The lower the Gleason grade group, the less aggressive the cancer; conversely, the higher the Gleason grade group, the more aggressive the prostate cancer.

Bottom Line: The Gleason grading system is an effective, reliable and time-tested means of determining the biological potential of any given prostate cancer to grow and spread, of vital importance in helping guide the appropriate treatment. 

Coming next week…Prostate Cancer Risk Assessment: A Sensible Guide to Appropriate Treatment.

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

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s 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

Your Prostate Biopsy Report

June 8, 2019

Andrew Siegel MD   6/8/19

Today’s entry will enable you to make sense of the prostate biopsy report, which can be a source of confusion for patients.

Prostate Histology (the study of the microscopic structure of tissues) in 30-seconds   

The prostate gland is divided into anatomical subdivisions known as lobes. It is organized like a tree with a major trunk draining each lobe, each trunk served by many ducts which progressively branch out into smaller and smaller ducts. At the end of each duct is an acinus (Latin, meaning berry), analogous to a leaf at the end of a tree branch. Each acinus is lined by cells that secrete prostate fluid, a nutrient vehicle for sperm that is an important component of semen. Each acinus is surrounded by a basement membrane that is a barrier layer that separates the secretory cells from surrounding structures.

ducts and acini from AUA AUAnet.org

Microscopic view of healthy prostate ducts and acini (plural of acinus); image from AUAnet.org

 

Pathologists are the doctors that study biopsies under the microscope and make the diagnosis of cancer.  By staining tiny fragments of tissue cut in slices thinner than a hair, elements of the cell are highlighted that would not normally be apparent, identifying cancer.

What are the possible outcomes of the prostate biopsy?

There are four possibilities:

  • Benign prostate tissue
  • HGPIN (High Grade Prostate Intraepithelial Neoplasia)
  • ASAP (Atypical Small Acinar Proliferation)
  • Prostate Cancer

What is benign prostate tissue?

This is a biopsy report indicative of healthy prostate tissue, with no evidence of cancer or pre-cancer.  This is the kind of report that urologists are delighted to convey to patients.

What is HGPIN?

HGPIN is an acronym for “High Grade Prostate Intraepithelial Neoplasia.” HGPIN occurs in 0.6 – 24% of biopsies. It is a microscopic abnormality marked by an abnormal appearance and proliferation of cells within ducts and acini, but the abnormal cells do not extend beyond the basement membrane to the surrounding parts of the prostate (as occurs with prostate cancer). HGPIN is considered a pre-malignant precursor lesion to prostate cancer.

Current recommendations for men who are found to have one site of HGPIN (uni-focal HGPIN) are to follow-up as one would follow for a benign biopsy, with annual digital rectal exam and PSA.  However, if there are multiple biopsies indicating HGPIN (multifocal HGPIN), a more vigilant follow-up may be necessary, particularly if the PSA is elevated, accelerated or if there is ASAP (see below) found adjacent to the HGPIN. Repeat biopsy is a consideration, with sampling of identified HGPIN areas and adjacent sites. The more cores containing HGPIN on an initial prostate biopsy, the greater the likelihood of cancer on subsequent biopsies. The overall risk for prostate cancer following the diagnosis of multifocal HGPIN is about 25%.

What is ASAP?

ASAP is an acronym for “Atypical Small Acinar Proliferation.” ASAP occurs in 5 – 20% of biopsies. It is a microscopic abnormality marked by a collection of prostate acini that are suspicious but not diagnostic for prostate cancer, falling below the diagnostic “threshold.” The risk for cancer following the diagnosis of ASAP on re-biopsy is 40-50%. It is recommended that men with ASAP should undergo re-biopsy within 3 to 6 months, with sampling of identified areas and adjacent sites.

What is cancer?

All cancers begin with a cell that goes rogue during its replication—a cell gone wild—reproducing and proliferating endlessly and creating a mass of identical cells. This process is often caused by a single mutation.  Cancer is defined as the uncontrolled and disorganized growth of abnormal cells, as opposed to the controlled and organized means of replacing old cells after they become non-functional. Whereas normal cells grow, divide and die in an orderly fashion, cancer cells continue to grow, divide and form new abnormal cells.

Normal cells become cancer cells (malignant cells) when permanent such mutations in the DNA (deoxyribonucleic acid) sequence of a gene transform them into a growing and destructive version of their former selves. These abnormal cells can then divide and proliferate aberrantly and without control. Although damaged DNA can be inherited, it is much more common for DNA damage to occur by exposure to environmental toxins or from random cellular events.  Under normal circumstances, the body repairs damaged DNA, but with cancer cells the damaged DNA is unable to be repaired.

As cancer cells grow they form a mass of cells (1 cubic centimeter of cancer consists of about 100 million cells) and the properties of the mutated cells allow them to encroach upon, invade and damage neighboring tissues. They can also break off from their site of origin via blood and lymphatic vessels and travel to and invade remote organs including lymph glands, liver, bone and brain, a situation known as metastasis.

Prostate cancer is a microscopic abnormality marked by an abnormal appearance and proliferation of cells within prostate ducts and acini (plural of acinus) that have broken through the basement membrane barrier to involve the deeper tissues of the prostate. The appearance of prostate cancer cells and their architectural patterns of growth differ from normal cells in ways that enable the pathologist to recognize and diagnose the biopsy as cancer. The degree to which these tissues demonstrate malignancy allows the pathologist to assign a grade to the cancerous tissue. The higher the grade, the more profound the malignant changes.

If the prostate biopsy demonstrates prostate cancer, the pathologist will provide a detailed report indicating the following:

  • Number of cores showing cancer
  • Percent of cancer involvement in each core
  • Location of the cores with cancer
  • Gleason score (the pathologist’s numerical quantification of aggressiveness)
  • Biopsy map

Most prostate cancers are “adenocarcinomas” (adeno- “pertaining to a gland” and carcinoma– “a cancer that develops in epithelial cells”) — a type of malignancy that originates from glandular cells. On occasion, a prostate adenocarcinoma is found to be an “intra-ductal carcinoma,” a proliferation of malignant prostate cells that fill and distend the inside space of prostatic ducts and acini, with the cells around the basement membrane largely preserved. Intra-ductal prostate cancer is often invasive, high grade, and typically has large tumor volumes.

Rarely, a prostate cancer is found to be a “small cell carcinoma,” a type of malignancy that originates from neuro-endocrine cells. This high grade and aggressive cancer accounts for only about 1% of prostate cancers and is typically diagnosed at an advanced stage, tends to progress rapidly and has a poor prognosis with an average survival of less than one year.

Coming next week: The Gleason grading system for prostate cancer.

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

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s 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

 

 

 

 

Prostate Biopsy: What is Involved?

June 1, 2019

Andrew Siegel MD   6/1/19

Today’s entry takes you through the details of a prostate biopsy, which–although scary in concept–is a brief and simple office procedure that obtains valuable and potentially life-saving information.  

Hopefully, you will never need to undergo a biopsy of your prostate gland.  However, many men will ultimately require one if there is concern for, or suspicion of the possibility of prostate cancer—most commonly based upon an elevation in PSA, a PSA acceleration, or an abnormal digital rectal exam.  Other indications are to reevaluate pre-cancerous lesions, including high grade prostate intra-epithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP), monitoring patients on active surveillance, and in the evaluation of men who have received prior prostate cancer treatment and have rising PSAs.

Although digital rectal exam, PSA blood testing, and MRI are suggestive and helpful tests, it is the biopsy that is definitive. “The buck stops here” with prostate biopsy, the most conclusive diagnostic test. 

Diagram_showing_a_prostate_biopsy_CRUK_472_pl

Attribution of Image Above: Cancer Research UK uploader [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)%5D…Note prostate, ultrasound probe and needle biopsy, translated from Polish

Prostate ultrasound is a means of prostate imaging using sound waves (like sonar on a submarine) generated by an ultrasound probe placed in the rectum. Reflected echoes create a high-resolution image of the prostate to measure the prostate volume, check for abnormalities, and precisely guide biopsies. The ultrasound image alone is not sufficient to diagnose prostate cancer without a tissue biopsy. MRI is often used prior to the biopsy to ascertain if there are any discrete abnormalities that can be targeted by the biopsy.

Preparation for ultrasound-guided prostate biopsy involves a Fleet enema the evening before the biopsy to cleanse the rectum, discontinuing blood thinner medications for a week or so prior to the procedure and starting a short course of oral antibiotics prior to the biopsy, since the biopsies are performed via the rectum.

The prostate biopsy can be performed using a local anesthetic or, alternatively, with intravenous sedation. I prefer to do the biopsies in the office setting using intravenous sedation provided by an anesthesiologist, which makes the experience much more pleasant for the patient and avoids the need for local anesthetic injections into the prostate, which can increase the risk of infection. Two antibiotics are administered intravenously immediately prior to the biopsy.

The ultrasound/biopsy is about a 10-15-minute procedure, although one needs to arrive 30 minutes prior to and remain for about 30 minutes or so after the procedure. In the knee-chest position while lying on one’s side, the ultrasound probe is gently placed into the rectum.  After obtaining imaging and volume measurements, prostate biopsies are obtained with a spring-driven needle device that is passed through the needle guide attached to the ultrasound probe. The biopsies are tiny, about the size of eyelashes.  Generally, a minimum of 12 biopsies are obtained—six from each side with two biopsies each from the apex, mid-gland and base, providing a pathological “map” of the prostate. Each biopsy is placed in a separate specimen container noting the site of the biopsy and is carefully examined by a pathologist to make a diagnosis.

If an abnormality is visualized on ultrasound—classically a hypo-echoic region (an area with less echoes than adjacent prostate tissue)— this specific area will be biopsied as well. Often, MRI is performed prior to the biopsy and any specific area of suspicion identified on MRI is matched with the ultrasound, and targeted biopsies are obtained of these areas, as well as the standard 12 mapping biopsies. MRI/ultrasound fusion-guided biopsy is a means of fusing pre-biopsy MRI prostate imaging with ultrasound-guided prostate biopsy images in real time, so that the suspicious regions seen on MRI can be precisely targeted. Fusion-guided biopsies require sophisticated hardware and software technology and the combined efforts of the radiologist, technician and urologist. Alternatively, cognitive-guided biopsies are ultrasound-guided biopsies performed while simultaneously viewing the pre-biopsy MRI images to target the regions of concern.

After the biopsy, it is important to stay well hydrated, complete the prescribed antibiotics, and to take it easy for a day or so. Urinary and/or rectal bleeding following a biopsy is common and typically resolves within a few days or so.  However, it is not uncommon to experience some blood in the semen for up to 6 weeks after the biopsy. It generally takes 7-10 days or so to receive the biopsy results.

Trans-perineal (via the anatomical region between scrotum and anus) mapping prostate biopsies are sometimes done as an alternative to the trans-rectal biopsy described above. Ultrasound is used to image the prostate and numerous mapping biopsies—typically at 5 mm intervals—are done via a perineal template. This provides a pathological map of the entire prostate, sometimes used to obtain a primary biopsy but more often used as a confirmatory biopsy that improves staging because of the number of biopsies obtained at precise anatomical locations.

Coming next week…What you will learn from the prostate biopsy report.

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

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s 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

 

Prostate Cancer Screening Biomarkers: What You Need To Know

May 25, 2019

Andrew Siegel MD  5/25/19

Before we get to the main course, let’s begin with a little appetizer—some trivia about urology, the occupation of yours truly.  There are not many of us around; there are currently 12,700 practicing urologists in the USA, 1 for every 25,000 Americans.  90% of  are male and 10% are female. 57% of urologists are in private practice and the remainder are employed by hospitals or academic medical centers. 40% of urologists have a primary subspecialty, oncology (cancer) being the most common.

Although I have subspecialty training and board certification in female pelvic medicine and reconstructive surgery, I enjoy general urology, treating both male and female adults with a variety of conditions (voiding and sexual dysfunction, incontinence, pelvic organ relaxation, urological cancers, infections, kidney stones, bleeding, vasectomy, etc.), the balance between office and surgical practice and—most importantly– the fact that as urologists, we can help most patients improve their quality and quantity of life.  

 

Bi·o·mark·er

/ˈbīōˌmärkər/
noun
plural noun: biomarkers
  1. a measurable substance in an organism whose presence is indicative of some phenomenon such as disease, infection, or environmental exposure.

Prostate specific antigen (PSA) was the first prostate cancer biomarker, singularly responsible for revolutionizing the diagnosis and follow-up of prostate cancer. There are several new biomarkers that can help with the decision of whether or not to biopsy the prostate as well as to inform and support prostate cancer management decisions (active surveillance vs. active treatment, the specific means of treatment for early and localized cancer, and when to pursue androgen deprivation therapy).

Prostate health index (PHI): This is a compilation of several different PSA sub-types, including pro-PSA, free PSA and total PSA, into a single score. It can help discriminate between higher and lower grade disease. PHI score coupled with other factors including age, prostate volume, digital rectal examination (DRE) {abnormal DRE vs. normal DRE} and biopsy history (prior prostate biopsy vs. no prior prostate biopsy) are used to help determine the need for biopsy in a patient with suspected prostate cancer.

Prostate cancer antigen (PCA3) urine test: PCA3 is a specific type of RNA (ribonucleic acid) that is released in high levels by prostate cancer cells. Its expression is 60-100 times greater in prostate cancer cells than benign prostate cells, which makes this test much more specific for prostate cancer than PSA. The first ounce of urine voided immediately after prostate massage (a vigorous DRE with the intent of milking the prostate) is rich in prostatic fluid and cells and is collected and tested for the quantity of PCA3 genetic material present. Urinary levels of PCA3 are not affected by prostate enlargement or inflammation, as opposed to PSA levels. PCA3 > 25 is suspicious for prostate cancer.

4Kscore test:  4Kscore test measures blood levels of four different prostate-derived proteins: total PSA, free PSA, intact PSA and human kallikrein 2. Levels of these biomarkers are combined with the patient’s age, DRE, and history of prior biopsy. These factors are processed using an algorithm to calculate the risk of finding an aggressive prostate cancer (Gleason score 7 or higher) if a prostate biopsy were to be performed. The test can increase the accuracy of prostate cancer diagnosis, particularly in its most aggressive forms.  It cannot be used if a patient has had a DRE in the previous 4 days, nor can it be used if one has taken finasteride (Proscar) or dutasteride (Avodart) within the previous six months. Additionally, it cannot be used in patients who have undergone any procedure to treat symptomatic prostate enlargement or any invasive urologic procedure in the prior 6 months.

Apifiny test:  This test measures the immune response to prostate cancer, detecting autoantibody proteins in the blood that are produced against prostate cancer cells. It is a risk assessment tool that does not rely on PSA. A score of 1-100 is given: the higher the score, the greater the chance for the presence of prostate cancer.

Biomarker to confirm a negative (benign) biopsy:

ConfirmMDx:  Since a biopsy of the prostate samples only a small volume of the total prostate, it is possible to have benign biopsy results when in fact an underlying cancer was missed.  This particular assay is done on prostate tissue derived from a negative biopsy to help determine its accuracy. It quantitates the chemical status of certain genes to detect abnormal changes associated with the presence of prostate cancer. ConfirmMDx detects a “halo” associated with the presence of cancer at the DNA level, which may be detected in prostate cancer tissue despite a normal microscopic appearance. This test helps identify low risk men who may forego a repeat biopsy and high risk men who would benefit from a repeat biopsy.

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

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s 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

 

Prostate MRI: What You Should Know

May 18, 2019

Andrew Siegel MD  5/18/2019

MRI (magnetic resonance imaging) is a high-resolution test that is an important tool for prostate cancer diagnosis, targeting of biopsies, clinical staging, surgical planning, follow-up of prostate cancer patients managed with active surveillance and in the evaluation of recurrent prostate cancer following treatment. A shout-out to Dr. Robert Waxman, who provided the MRI images seen below. 

MRI uses a powerful magnet to enable viewing of the prostate gland and surrounding tissues in multiple planes of view with the advantage of not requiring radiation. The planes are axial (cross section), sagittal (the plane that divides the body into left and right) and coronal (a plane dividing the body into dorsal and ventral parts). The axial images are by far the most important images of the study. MRI identifies areas suspicious for cancer and enables “targeted” biopsies as opposed tosystematic” biopsies. Although useful in the diagnostic evaluation of any man who has a suspicion of prostate cancer, it is particularly beneficial in men who have had previous benign prostate biopsies who have persistent PSA elevations or accelerations.

MRI is a valuable part of the diagnostic armamentarium, increasing the detection rate of clinically significant (Gleason score 7 or higher) prostate cancers, while reducing the detection rate of clinically insignificant (Gleason score 6) cancers. MRI provides anatomical details about the neuro-vascular (nerve and blood vessel) bundles, urinary bladder, seminal vesicles, pelvic lymph nodes, bowel and pelvic bones and beneficial staging information on tumor extension beyond the prostate capsule, pelvic lymph node enlargement and seminal vesicle involvement.

Prostate MRI is performed at specialty imaging centers.  Preparation involves a Fleet enema to clear gas from the rectum that can generate artifacts on the MRI images making interpretation suboptimal.  A coil placed in the rectum (endo-rectal coil) is no longer necessary as it was in prior versions of MRI. The study is done before and after the injection of about 20 cc of intravenous contrast to optimize the results.

Note: MRI cannot be performed under the following circumstances: pacemaker, recent coronary artery stent placement, ferromagnetic brain aneurysm clips and the presence of metal near the spinal cord, e.g., bullet fragments.

Refinements in MRI involve diffusion and perfusion studies. Diffusion is the movement of water into tissues; because prostate cancer cells are more tightly packed than normal cells, diffusion is often restricted with prostate cancers. Perfusion is the circulation of blood to tissues; because prostate cancers are hyper-vascular (increased blood supply), with the injection of the intravenous contrast there is increased perfusion with prostate cancers.

The value of prostate MRI is highly operator-dependent and requires both a quality study and interpretation by a skilled and experienced radiologist. Sophisticated software performs image analysis, assisting radiologists in interpreting and scoring MRI results. A validated scoring system known as PI-RADS (Prostate Imaging Reporting and Data System) is used. This scoring system helps urologists make decisions about whether to biopsy the prostate and, if so, how to optimize the biopsy.

PI-RADS      

I     most probably benign (clinically significant cancer highly unlikely)

II    probably benign (clinically significant cancer unlikely)

III   indeterminate (clinically significant cancer equivocal) — 20% chance

IV   probably cancer (clinically significant cancer likely) — 50% chance

V   most probably cancer (clinically significant cancer highly likely) —75% chance

Of note, the IV and V groups are the same, differentiated only by the size of the suspicious region. In the IV group the abnormality is < 1.5 cm; in the V group the abnormality is > than 1.5 cm in diameter.

Now let’s play radiologist.  Can you identify the suspicious regions in the following two images?  There is a magnified view of the abnormal sites at the end of this entry.  Radiology clue: when you view images, always be on the look out for asymmetries between the left and right.

MRI1

Patient 1 with a PIRADS-5 lesion

 

MRI2

Patient 2 with a PIRADS-5 lesion with mass effect on the rectum and likely extra-capsular extension

MRI is by no means a perfect test, as clinically significant cancers (particularly small ones) are not always apparent on MRI, and PIRADS-4 and PIRADS-5 lesions when biopsied are not always found to contain clinically significant cancers. An additional concern is its expense.  Some urologists believe in obtaining a prostate MRI on all patients prior to performing a prostate biopsy, whereas others reserve MRI for patients with a previous negative biopsy in the face of a rising PSA. In the former setting, a biopsy remains the only definitive means of assessment regardless of the PIRADS score, one of the key utilities of the MRI being to help precisely target the biopsy.  However, in the latter setting, when the MRI reading is PIRADS-1 or PIRADS-2, a repeat biopsy can often be avoided.

Fact: PSA, DRE and MRI are all useful and informative tests, but the prostate biopsy (tissue sampling) is the only way to know for sure if one has prostate cancer.  In other words, whereas PSA, DRE and MRI are “suggestive,” the biopsy is “definitive.” “The buck stops here” applies to the biopsy.

unnamed

Magnified view of lesion of figure 1

 

unnamed (12

Magnified view of lesion of figure 2

Final note: Most insurance companies will readily cover the cost of a MRI study prior to doing a prostate biopsy.  The exception is CIGNA, which apparently cares more about its bottom line than the welfare of its insured patients.  I am constantly fighting with CIGNA-employed physicians in “peer-to-peer” conversations in an effort to get the company to pay for a pre-biopsy MRI.  My last such conversation was two days ago and sadly, I have never prevailed.

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

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s 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

 

Laser Vaginal Therapy: Hope or Hype?

May 11, 2019

Andrew Siegel MD 5/11/2019

HAPPY MOTHER’S DAY!

For better or for worse, we are living in the era of “vaginal rejuvenation.”  Procedures referred to as “designer vaginoplasty,” “re-virgination,” “reduction labioplasty,” “G-spot amplification,” “platelet-rich plasma (PRP) injections,” “vaginal bleaching,” etc., have come into vogue as expensive plastic procedures advertised by some entrepreneurial physicians for cash-paying patients. Within the domain of “vaginal rejuvenation,” the last few years have also witnessed an explosion in the availability of office-based vaginal laser therapies for a variety of conditions, including vaginal dryness and other symptoms of menopause, vaginal (laxity) looseness, and stress urinary incontinence.

Vagina collage public domain

Vaginal Collage (public domain)

LASER = light amplification and stimulated emission of radiation

The theorized mechanism of action of laser therapy is collagen and elastin fiber remodeling, growth of new collagen, blood vessel ingrowth and growth factor infiltration.  The goal is the restoration of vaginal elasticity, suppleness and moistness that often decline after menopause with the cessation of estrogen production, a hormone that contributes vitally to female genital health.

In the USA, these procedures are costly and not covered by insurance. They are most commonly performed by gynecologists, but any MD with a license or their nurse practitioners or physician assistants can legally perform these laser procedures.  Lasers are expensive to purchase or lease and private physicians charge an “arm and a leg” to treat the vagina, since these procedures are outside the domain of health insurance.

The problem is the lack of scientific evidence regarding effectiveness of laser procedures as well as the possibility of serious adverse effects (including itching, burning, redness, scarring, swelling, pain during intercourse and chronic pain). In July of 2018, the FDA issued a warning against the use of energy-based devices– including lasers and radio-frequency devices– for vaginal rejuvenation and vaginal cosmetic procedures.

The bottom line is that although there is some evidence of effectiveness based upon observational studies, there exists a strong need for long-term, large, randomized and placebo-controlled clinical trials to evaluate the safety and effectiveness of these vaginal laser procedures before they can be recommended.

As a urologist, I often use lasers for fragmenting stones in the urinary tract (bladder, ureters and kidneys) and for creating a channel through an obstructed prostate gland. These are legitimate and bonafide uses of lasers in medicine. My urology group does not utilize vaginal laser therapy (although its use was considered, but voted down after considerable research).  I do have some patients who have had vaginal laser procedures outside of my practice to manage symptoms of menopause, vaginal laxity and stress urinary incontinence. Anecdotally, I have one patient who speaks very highly of the fractional laser therapy she received for post-menopausal dryness, which seemed to improve her situation.

With respect to vaginal laxity and stress urinary incontinence, my feeling is that as fabulous and high-tech as lasers are, in these two cases lasers are a solution in search of a problem and are ineffective options for the management of these problems. If a woman truly has vaginal laxity–often accompanied by pelvic organ prolapse–or significant stress urinary incontinence she will often benefit from surgical therapy if unresponsive to conservative treatments.  Furthermore, my advice is to stay away from vaginal bleaching, G-spot amplification, PRP injections, and re-virgination insanity.  Labiaplasty is a reasonable consideration if a woman has outsized labia that get in the way of life’s activities, but otherwise my advice is to maintain a healthy lifestyle and pursue pelvic floor exercises as a means of vaginal fitness.

Bottom Line:  Laser Vaginal Therapy: Mostly hype with a bit of hope.  As always, caveat emptor (buyer beware)!

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

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s 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

one-sheet-poster

 

Refinements and Nuances of PSA Testing: What You Need to Know

May 4, 2019

Andrew Siegel MD  5/4/19

mannequin pis

Above photo is of the famous Mannekin Pis statue in Brussels

Last week’s entry discussed the basics of PSA—”PSA 101” if you will. Today is the “300-level  course” that reviews refinements in PSA testing that make the test more valuable, meaningful and predictive.  

What are some of the refinements and nuances in PSA (Prostate Specific Antigen) testing?

PSA Velocity:  Comparing one’s PSA values year-to-year is most informative. Generally, PSA will increase by only a small increment, reflecting benign prostate growth associated with the aging process. If PSA accelerates faster than anticipated—a condition known as accelerated PSA velocity—further evaluation is indicated.  The bottom line is that an isolated PSA (out of context) is much less meaningful than a series of one’s PSAs over time.

Please note: Many labs use a PSA of 4.0 as a cutoff for abnormal, so it is possible that one can be falsely lulled into the impression that their PSA is normal.  For example, if one’s PSA is 1.0 and a year later it is 3.0, it is still considered a “normal” PSA (because it is less than 4.0) even though it has tripled (highly suspicious for a problem) and mandates further investigation.  So, it is worthwhile knowing your actual PSA level, similar to being aware of your cholesterol level.

PSA Density:  The larger the prostate, the more PSA that is manufactured.  PSA density (PSA divided by prostate volume) is the PSA level corrected to prostate size. The prostate volume can be determined by imaging studies including ultrasound or MRI.  PSA elevations are less worrisome under the circumstance of an enlarged prostate.

A PSA density > 0.15 is concerning for prostate cancer.

Free PSA:  PSA circulates in the blood in two forms: a “free” form in which the PSA is unbound, and a “complex” PSA in which the PSA is bound to a protein. The free PSA/total PSA ratio can offer a predictive value (similar to how HDL cholesterol/total cholesterol can be helpful in a person with an elevated cholesterol level). The higher the free to total PSA ratio, the greater the chance that benign enlargement of the prostate is the underlying source of the PSA elevation.

In men with a PSA ranging from 4-10, the probability of cancer is:

9-16% if the free/total PSA ratio is greater than 25%

18-30% if the ratio is 19-25%

27-41% if the ratio is 11-18% 

49-65% if the ratio is less than 10%

4Kscore test: The 4Kscore Test is a refinement that measures the blood content of four different prostate-derived proteins: total PSA, free PSA, intact PSA and human kallikrein 2. Levels of these biomarkers are combined with a patient’s age, DRE (digital rectal examination) status (abnormal DRE vs. normal DRE), and history of prior biopsy status (prior prostate biopsy vs. no prior prostate biopsy). These factors are processed using an algorithm to calculate the risk of finding a Gleason score 7 or higher (aggressive) prostate cancer if a prostate biopsy were to be performed. The test can increase the accuracy of prostate cancer diagnosis, particularly in its most aggressive forms. (It cannot be used if a patient has received a DRE in the previous 4 days, nor can it be used if one has been on Avodart (dutasteride) or Proscar (finasteride) within the previous six months. Additionally, it cannot be used in patients that have within the previous six months undergone any procedure to treat symptomatic prostate enlargement or any invasive urologic procedure that may be associated with a PSA elevation.)

How is PSA used in men diagnosed with and treated for prostate cancer?

PSA is unquestionably the best marker to gauge prostate cancer status in the follow-up of men who have been treated for prostate cancer by any means or in those men who are on active surveillance.

After surgical removal of the prostate gland for cancer the PSA should be undetectable and after radiation therapy the PSA should decline substantially to a reading of usually less than 1.0. Rising PSA levels after treatment may be the first sign of cancer recurrence.  Such a “biochemical” relapse typically precedes a “clinical” relapse by months or years.  If a man on active surveillance has consecutive substantial elevations in PSA level, it signals the possibility of more aggressive disease that may require active intervention.

Is PSA the definitive test for prostate cancer?

No! PSA is the definitive test for monitoring prostate cancer and a good, but imperfect screening test since the PSA can be elevated in the absence of prostate cancer and low in the presence of prostate cancer.

An elevated or accelerated PSA, abnormal digital rectal exam and suspicious MRI are all helpful tests, but remember that the definitive and conclusive test for prostate cancer is the ultrasound-guided prostate biopsy.

“The buck stops here” with prostate biopsy, the conclusive test for prostate cancer.

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

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s 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

 

PSA is “Worthless”: MORE FAKE NEWS!

April 27, 2019

Andrew Siegel MD  4/27/19

When I use the acronym PSA, I do not refer to “Public Service Announcement,” nor “Pacific Southwest Airlines,” nor “Polar Surface Area.”  In the context of this entry, PSA is Prostate Specific Antigen, an important blood test that helps screen for prostate cancer and monitor prostate cancer in those diagnosed with the disease.

What is PSA?

PSA is a chemical produced by the prostate gland, that functions to liquefy semen following ejaculation, aiding the transit of sperm to the egg.  A small amount of PSA filters from the prostate into the blood circulation and can be measured by a simple blood test. In general, the larger the prostate size, the higher the PSA level, since larger prostates produce more PSA. As a man ages, his PSA rises based upon the typical enlarging prostate that occurs with growing older.

How is PSA used to screen for prostate cancer?

Using PSA testing, about 90% of men have a normal PSA.  Of the 10% of men with an elevated PSA, 30% or so will have prostate cancer. In a recent study of 350,000 men with an average age of 55, median PSA was 1.0. Those with a PSA < 1.5 had a 0.5% risk of developing prostate cancer, those between 1.5-4.0 had about an 8% risk, and those > 4.0 had greater than a 10% risk.

Although it is an imperfect screening test, PSA remains the best tool currently available for detecting prostate cancer.  It should not be thought of as a stand-alone test, but rather as part of a comprehensive approach to early prostate cancer detection.  Baseline PSA testing for men in their 40s is useful for predicting the future potential for prostate cancer. The most informative use of PSA screening is when it is obtained serially, with comparison on a year-to-year basis providing much more meaningful information than a single, out-of-context PSA.

I have practiced urology in both the pre-PSA and the post-PSA era. In my early career (pre-PSA era), it was not uncommon to be called to the emergency room to consult on men who could not urinate (a condition known as urinary retention), who on digital rectal exam were found to have rock-hard prostate glands and imaging studies that showed diffuse spread of prostate cancer to their bones—metastatic prostate cancer with a grim prognosisFortunately, in the current era, that scenario occurs extremely infrequently because of PSA screening. These days, most men who present with metastatic disease are those who have not had PSA screening as part of their annual physical exams.

Is there any truth that the PSA test is worthless?

A major backlash against screening occurred a few years ago with the United States Preventive Services Task Force (USPSTF) grade “D” recommendation against PSA screening and their call for total abandonment of the test. This organization counseled against the use of PSA testing in healthy men, postulating that the test does not save lives and leads to more tests and treatments that needlessly cause pain, incontinence and erectile dysfunction. Of note, there was not a single urologist on the committee. The same organization had previously advised that women in their 40s not undergo routine mammography, setting off another blaze of controversy. Uncertainty in the lay press prompted both patients and physicians to question PSA testing and recommendations for prostate biopsy.

Is there really any harm in screening?  Although there are potential side effects from prostate biopsy (although they are few and far between) and there certainly are potential side effects with treatment, there are no side effects from drawing a small amount of blood. The bottom line is that when interpreted appropriately, the PSA test provides valuable information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. Marginalizing this important test does a great disservice to patients who may benefit from early prostate cancer detection. I give the USPSTF an “F” for their ill-advised recommendation, the aftermath of which is, sadly, a spike of men with higher PSA levels and more aggressive and advanced prostate cancer.

IMG_0556

Since the early 1990s, prostate cancer mortality has declined, but the aftermath of the USPSTF recommendation was a spike in prostate cancer death rates

 

mmtr13hr

The USPSTF gets the Horse’s Ass award for disservice to the well- being of mankind

Why bother screening for prostate cancer?

Excluding skin cancer, prostate cancer is the most common cancer in men (1 in 9 lifetime risk), accounting for one-quarter of newly diagnosed cancers in males.  Prostate cancer causes absolutely no symptoms in its earliest stages and the diagnosis is made by prostate biopsy done on the basis of abnormalities in PSA levels and/or digital rectal examination. An elevated or accelerated PSA that leads to prostate biopsy and a cancer diagnosis most often detects prostate cancer in its earliest and most curable state. Early and timely intervention for those men with aggressive cancer results in high cure rates and avoids the potential for cancer progression and consequences that include painful cancer spread and death.

The upside of screening is the detection of potentially aggressive prostate cancers that can be treated and cured. The downside is the over-detection of unaggressive prostate cancers 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 cancers, with adverse consequences from necessary treatment not being given.

Why is PSA elevated in the presence of prostate cancer?

Prostate cancer cells do not make more PSA than normal prostate cells. The elevated PSA occurs because of a disruption of the cellular structure of the prostate cells. The loss of this structural barrier allows accelerated seepage of PSA from the prostate into the blood circulation.

Does an elevated PSA always mean one has prostate cancer?

There is no letter C (for cancer) in PSA.  Not all PSA elevations imply the presence of prostate cancer.  PSA is prostate organ-specific but not prostate cancer-specific. Other processes aside from cancer can cause enhanced seepage of PSA from disrupted prostate cells. These include prostatitis (inflammation of the prostate), benign prostatic hyperplasia (BPH, an enlargement of the prostate gland), prostate manipulation (e.g., a vigorous prostate examination, prostate biopsy, prolonged bike ride, ejaculation, etc.).

Why is PSA an imperfect screening test?

PSA screening is imperfect because of false negatives (presence of prostate cancer in men with low PSA) and false positives (absence of prostate cancer in men with high PSA). Despite its limitations, PSA testing has substantially reduced both the incidence of metastatic disease and the death rate from prostate cancer.

Who should be screened for prostate cancer?

Men age 40 and older who have a life expectancy of 10 years or greater are excellent candidates for PSA screening. Most urologists do not believe in screening or treating men who have a life expectancy of less than 10 years. This is because prostate cancer rarely causes death in the first decade after diagnosis and other competing medical issues often will do so before the prostate cancer has a chance to.  Prostate cancer is generally a slow-growing process and early detection and treatment is directed at extending life well beyond the decade following diagnosis.

The age at which to stop screening needs to be individualized, since “functional” age trumps “chronological” age and there are men 75 years old and older who are in phenomenal shape, have a greater than 10-year life expectancy and should be offered screening. This population of older men may certainly benefit from the early diagnosis of aggressive prostate cancer that has the potential to destroy quantity and quality of life. However, if a man is elderly and has medical issues and a life expectancy of less than 10 years, there is little sense in screening. Another important factor is individual preference since the decision to screen should be a collaborative decision between patient and physician.

Bottom Line: PSA screening detects prostate cancer in its earliest and most curable stages, before it has a chance to spread and potentially become incurable.  PSA screening has unequivocally reduced metastases and prostate cancer death and it is recommended that it be obtained annually starting at age 40 in men who have a greater than a 10-year life expectancy.  PSA testing in men who have been diagnosed with prostate cancer provides valuable information about pre-treatment staging, risk assessment and monitoring after treatment.  Although PSA has many shortcomings, when used intelligently and appropriately, it will continue to save lives.

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

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s 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

 

IT’S ALL MESHED UP: FDA Decision on Pelvic Prolapse Repair Mesh Sets Back Women’s Health

April 20, 2019

Andrew Siegel MD 4/20/19

This past Tuesday, the U.S. Food and Drug Administration (FDA) ordered the manufacturers of all remaining surgical mesh products for trans-vaginal repair of pelvic organ prolapse (Boston Scientific and Coloplast) to stop selling and distributing their products in the USA, effective immediately. According to the FDA, the manufacturers in their premarket applications failed to provide reasonable assurance that the benefits of the products outweighed their risks, compared with trans-vaginal surgical tissue repair without mesh. The inaccessibility of these products will severely hamper treatment options for many women with pelvic organ prolapse and is a genuine disservice to the female population and a blow to women’s health, which has otherwise made major strides forward in the last few decades.

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Boston Scientific Uphold Lite Mesh

 

Clearly, the issue is NOT the mesh, which is a synthetic material—polypropylene—that has been used safely and effectively for years as a suture material and for virtually all hernia repairs. Rather, the issues are threefold—inappropriate manufacturing company marketing, inexperienced surgeon implanters, and our “ambulance-chasing” financially-motivated legal culture.

For years, the manufacturers of these mesh products—many of which ultimately removed themselves from the mesh business—assertively marketed these mesh products in “weekend” courses to surgeons (who were not surgically trained to perform these procedures).  These inexperienced physicians then became avid mesh implanters and often engendered complications in the patients whom they implanted, setting the scene for law firms to aggressively advertise and seek clients for litigation.

Sadly, there is excellent scientific data to support the safety and efficacy of vaginal mesh when done in properly selected patients by skilled pelvic surgeons. Millions of such vaginal mesh surgeries have been performed successfully with minimal complications by pelvic surgeons with training in a subspecialty of urology and gynecology—female pelvic medicine and reconstructive surgery. This requires several years of specialty fellowship training after completion of urology or gynecology residency and a second board examination in addition to board certification in urology or gynecology, thus most in this subspecialty are dual board certified.

Why mesh in the first place?  Why use a synthetic material when native tissues can be used?  The answer lies in the nature of pelvic organ prolapse.  Analogous to a hernia, pelvic organ prolapse is a weakness in connective tissue support allowing a pelvic organ (often the bladder) to pooch down into the vagina and at times outside the vagina, causing an annoying bulge, pressure and often difficulties with urination. The mesh principle is using a structurally sound material instead of a patient’s defective connective tissues (that has already failed) to rebuild support. If a brick wall collapses because of structural issues, would one use the same bricks to rebuild the wall?  Clearly the answer is no.  This is why polypropylene mesh is used in the vast majority of hernia repairs: hardy structural support is needed to compensate for the native connective tissue defect.

The mesh principle: For anatomic defects, using weakened/defective native tissues for a structural repair often causes failures.

In the properly selected patient operated on with the appropriate surgical technique by the experienced surgeon, the results of vaginal mesh repairs have been extraordinarily gratifying and nothing short of a paradigm shift from the native tissue repair era.  This procedure passes muster and the “MDSW” test—meaning I would readily encourage my mother, daughter, sister or wife to undergo the procedure if the situation called for it.

When performed by a skilled pelvic surgeon, the likelihood of cure or vast improvement is very high.   Meshes are strong, supple and durable and the procedure itself is relatively simple, minimally-invasive and amenable to doing on an outpatient basis.  When patients are seen several years after a mesh repair, their pelvic exams typically reveal restored anatomy with remarkable preservation of vaginal length, axis, caliber and depth.

Meshes act as a scaffold for tissue in-growth and ultimately should become fully incorporated by the body.  I think of the meshes in a similar way to backyard chain-link fences that have in-growth of ivy.  Meshes examined microscopically years after implantation demonstrate a dense growth of blood vessels and collagen in and around the mesh.

When mesh is used for bladder repair, there is rarely any need for trimming of the vaginal wall, which maintains vaginal dimensions as opposed to the native tissue repairs, which often demand some trimming of vaginal wall with alteration of vaginal anatomy.  Another advantage of the mesh repair is that if there is some uterine prolapse accompanying the dropped bladder, the base of the mesh can be anchored to the cervix and thus provide support to the uterus as well as the bladder, potentially avoiding a hysterectomy.

The bottom line is that mesh repairs for pelvic organ prolapse have been revolutionary in terms of the quality and longevity of results—a true game-changer.  They represent a dramatic evolution in the field of female urology and urological gynecology, offering a vast improvement in comparison to the pre-mesh era.

That said, they are not without complications, but the complication rates should be reasonably low under the circumstances of proper patient selection, a skilled and experienced surgeon performing the procedure, proper surgical technique, and proper patient preparation. Three factors are integral to proper mesh integration: mesh factors, patient factors and surgeon factors.

The gold standard mesh is a piece of large-pored, elastic, monofilament polypropylene—any other synthetic can result in integration issues.  This is the standard for sling surgery as well, and time has proved this to be the best synthetic mesh.

Patient considerations are very important as risk factors for integration problems include the following: compromised or poor-quality vaginal tissues; diabetes; patients on steroids; immune-compromised patients; radiated tissues; and tobacco users.

Foremost, a well-trained, experienced surgeon should be the one doing the mesh implantation. It is sensible to check if your surgeon is specialized, and if not, at least has significant clinical experience doing mesh procedures. It is particularly important that the surgeon performing the mesh implant is capable of taking care of any of the small percentage of complications that may arise and are most often quite manageable.

Again, many of the problems that have occurred are not intrinsic to the mesh itself, but are potentially avoidable issues that have to do with either the surgical technique used to implant the mesh or to patient selection.  Rather than addressing these issues, the FDA has chosen to throw out the proverbial “baby with the bath water,” leaving in the wake of this short-sighted decision many female patients who will needlessly suffer.

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. 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.

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

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Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s 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