Posts Tagged ‘Prostate Cancer 20/20’

Digital Rectal Exam of the Prostate: What You Need to Know

April 13, 2019

Andrew Siegel MD   4/13/19

A DRE is not a fancy and sophisticated high-tech “digital” as opposed to “analog” test.  “Digital” does not refer to a series of data represented by zeroes and ones, but rather to the digit that is used to perform the exam, typically the index finger of the examining physician.  “Rectal” is self-explanatory, referring to the anatomical structure entered to access the prostate gland.  

finger 2

The slender digit of yours truly

Caveat Emptor:  Always scrutinize the index finger of your urologist before allowing him or her to lay a finger on you…if they are sausage-like or have long nails… 

Please note well the following fact that is misunderstood by many patients:  Although the anus and rectum are the portals to the prostate, urologists are NOT colon and rectal doctors, nor do we do colonoscopies.  That is under the domain of the gastroenterologist or colo-rectal surgeon. Same portal, different organs!  Just because you have had a colonoscopy does not imply that you have had a proper DRE of the prostate. 

A DRE is a vital part of the male physical exam in which a gloved, lubricated finger is placed gently in the rectum in order to feel the outer, accessible surface of the prostate and gain valuable information about its health.  There are many positions in which to perform the test, but I prefer the standing, leaning forward with elbows on exam table position. Another position is the lying on your side, knees bent upwards towards chest position. Both are perfectly acceptable.

True story:  When I was on  the receiving end of my first DRE, I passed out and needed to be revived with an ammonia inhalant!  It has never happened again, but I do literally “see stars” during my annual exams, which are truly humbling.  My conclusion is that it is always better to give than receive. 

After age 40, an annual DRE is highly recommended. Although it is not a particularly pleasant examination, it is brief and not painful. Urologists do not relish doing this exam any more than patients desire receiving it, but it provides essential information that cannot be derived by any other means. If the prostate has an abnormal consistency, a hardness, lump, bump, or simply feels uneven and asymmetrical, it may be a sign of prostate cancer.  Prostate cancer most commonly originates in the peripheral zone, that which is accessed via DRE.

Digital Rectal Exam

Illustration above from PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families, written by yours truly

When teaching medical students, we often use hand anatomy to explain what the prostate feels like under different circumstances.  Turn your hand so that the palm is up and make a fist. The normal prostate feels like the spongy, muscular, fleshy tissue at the base of the thumb, whereas cancer feels hard, like the knuckle of the thumb.

DRE in conjunction with the PSA (prostate specific antigen) blood test is the best means of screening for prostate cancer. Detection rates for prostate cancer are highest when using both tests, followed by PSA alone, followed by DRE alone.

The pathological features of prostate cancers detected on an abnormal DRE are, in general, less favorable than those of cancers detected by a PSA elevation. In other words, if the cancer can be felt, we tend to worry about it more than if it cannot be felt, as it is often at a more advanced stage.

Fact: The PSA blood test is NOT a substitute for the DRE. Both tests provide valuable and complementary information about your prostate health.

Bottom Line:  This simple test can be life-saving, so please “man up” and endure the momentary unpleasantness.  Remember that prostate cancer is the number 1 malignancy in men (aside from skin cancer) and cancers can be discovered on the basis of an abnormal DRE, even in the face of normal PSA. 

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

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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

 

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Reduce Your Risk For Prostate Cancer

April 6, 2019

Andrew Siegel MD  4/6/19

baseball-players

(Thank you, PublicDomainPictures.net for image above)

If you don’t want to read further, one simple thought to remember: You likely know what to do to maintain cardiac health: HEART-HEALTHY IS PROSTATE HEALTHY 

One of nine men in the USA will develop prostate cancer, the most common male malignancy (aside from skin cancer). On a baseball field, that’s one of the nine players on the field.  That’s scary common!

It would be awesome if the disease was preventable and would certainly lighten our urological work load. Although we are not there yet, we have become wiser and more enlightened about the means of decreasing chances of developing prostate cancer and also about earlier detection. 

The risk factors for the prostate cancer are aging, genetics, race and lifestyle.  The first three factors are beyond one’s control, but lifestyle is a modifiable risk factor. A healthy lifestyle, including a wholesome and nutritious diet, weight management, regular exercise and the avoidance of tobacco and excessive alcohol, can lessen one’s risk for all chronic diseases–cardiovascular disease, diabetes and a host of cancers including prostate cancer.  It can also slow the growth and progression of prostate cancer in those afflicted.

Consider the fact that when Asian men—who have very low rates of prostate cancer—emigrate to western countries, their risk of prostate cancer increases over time. Clearly, a calorie-rich, nutrient-poor, Western diet and sedentary lifestyle is associated with a higher occurrence of many preventable problems, including prostate cancer.

Not uncommonly, pre-cancerous biopsies predate the onset of prostate cancer by many years. This, coupled with the increasing prevalence of prostate cancer with aging, suggests that the process of developing prostate cancer takes place over a prolonged period of time. It is estimated to take many years—often more than a decade—from the initial prostate cell mutation to the time when prostate cancer manifests itself with either a PSA (prostate specific antigen blood test) elevation or acceleration or an abnormal digital rectal examination. In theory, this provides the opportunity for preventive measures and intervention before the establishment of a cancer.

Ways to Reduce Risk for Prostate Cancer (and Detect it Early if it Occurs)                                  

  • Maintain a healthy weight. Obesity is correlated with an increased risk for prostate cancer occurrence, recurrence, progression and death.  Research suggests a link between a high-fat diet and prostate cancer. In men with prostate cancer, the odds of spread and death are increased 1.3-fold in men with a body mass index (BMI) of 30-35 and 1.5-fold in men with a BMI > 35. Furthermore, carrying the burden of extra weight increases the complication rate following prostate cancer treatments.
  • Eat real foods and avoid refined, over-processed, nutritionally empty foods; be moderate with animal fats and dairy consumption.   A healthy diet includes whole grains and plenty of colorful vegetables and fruits. Vegetables and fruits are rich in anti-oxidants, vitamins, minerals and fiber. Anti-oxidants help protect cells from injury caused by free radicals, which can incur cellular damage and potentially cause cancer. Fruits such as berries (strawberries, blackberries, blueberries and raspberries), red cabbage and eggplant contain abundant anthocyanins, anti-oxidant pigments that give red, blue and purple plants their vibrant coloring. Tomatoes, tomato products and other red fruits and vegetables are rich in lycopenes, which are bright red carotenoid anti-oxidant pigments. Cruciferous vegetables (broccoli, cauliflower, Brussel sprouts, kale and cabbage) and dark green leafy vegetables are fiber-rich and contain lutein, a carotenoid anti-oxidant pigment. A healthy diet includes protein sources incorporating fish rich in anti-inflammatory omega-3 fatty acids (salmon, sardines and trout), lean poultry and plant proteins (legumes, nuts and seeds). Processed and charred meats should be avoided.  Healthy vegetable-origin fats (olives, avocados, seeds and nuts) are preferred. An ideal diet that adheres to these general recommendations and is heart-healthy and prostate-healthy is the Mediterranean diet.
  • Avoid tobacco and excessive alcohol intake. Tobacco use is associated with more aggressive prostate cancers and a higher risk of prostate cancer progression, recurrence and death. Prostate cancer risk rises with heavy alcohol use, so moderation is recommended.
  • Stay active and exercise on a regular basis. Exercise lessens one’s risk of developing prostate cancer and decreases the death rate in those who do develop it. If stricken with prostate cancer, if one is physically fit, they will have an easier recovery from any intervention necessary to treat the disease.  Exercise positively influences energy metabolism, oxidative stress and the immune system. Pelvic floor muscle exercises benefit prostate health by increasing pelvic blood flow and decreasing the tone of the part of the nervous system stimulated by stress, which can aggravate urinary symptoms. Furthermore, pelvic floor muscle exercises strengthen the muscles surrounding the prostate so that if one develops prostate cancer and requires treatment, he will experience an expedited recovery of urinary control and sexual function.
  • Be proactive and see your doctor annually for a DRE (digital rectal exam) and a PSA (prostate specific antigen) blood test. The PSA test does not replace the DRE—both need to be done!  Abnormal findings on these screening tests are what prompt further evaluation, including MRI and prostate biopsy, the definitive means of diagnosing prostate cancer. The most common scenario that ultimately leads to a diagnosis of prostate cancer is a PSA acceleration, an elevation above the expected incremental annual PSA rise based upon the aging process.

Important: An isolated PSA (out of context) is not particularly helpful. What is meaningful is comparing PSA on a year-to-year basis and observing for any acceleration above and beyond the expected annual incremental change associated with aging and benign prostate growth. Many labs use a PSA of 4.0 as a cutoff for abnormal, so it is possible that you can be falsely lulled into the impression that your PSA is normal.  For example, if your PSA is 1.0 and a year later it is 3.0, it is still considered a “normal” PSA even though it has tripled (highly suspicious for a problem) and mandates further investigation.

  • Finasteride (Proscar and Propeciaand dutasteride (Avodart), commonly used to treat benign prostate enlargement, reduce prostate cancer risk. These medications block the conversion of testosterone to its activated form that promotes prostate growth and male-pattern baldness. They help prevent prostate cancer, shrink the prostate, can improve lower urinary tract symptoms, help avoid prostate surgery, and grow hair on one’s scalp…a fountain of youth dispensed in a pill form!

Bottom Line:  When it comes to health, it is advantageous to be proactive instead of reactive, making every effort to prevent problems instead of having to fix them.  The cliché “an ounce of prevention is worth a pound of cure” is relevant to prostate cancer as it is to other health issues including diabetes and heart disease. A healthy lifestyle, including a wholesome and nutritious diet, maintaining proper weight, exercising regularly and avoiding tobacco and excessive alcohol can lessen one’s risk of all chronic diseases, including prostate cancer.  Be proactive by getting a 15-second digital exam of the prostate and PSA blood test annually. 

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

 

 

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

 

 

 

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

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.  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

 

 

Shocking News: “You have prostate cancer.”

February 23, 2019

Andrew Siegel MD  2/23/19

A thank you shout-out to Dr. Stephen Peters, Director Anatomic Pathology Rutgers-NJ Medical School, for helping me to distill the complexity of cancer into simple and understandable terms.

cancer

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

One’s response to hearing the four words: “You have prostate cancer” is often predictable, although every reaction is unique. The initial feelings are usually shock, disbelief, confusion, numbness and even denial. Concerns and questions immediately surface, prompted by lack of information and fear of the unknown and of what the future might hold: How can this be possible? Why me? How can this be when I have no symptoms or pain?  Is this an error? Was my pathology report confused with that of another man? What is my prognosis? Can I be cured? Will I be alive to see my children married?  How will treatment affect my lifestyle? Will I be able to continue functioning as a man?  Will I lose urinary control?  How long do I have to live?  How is this going to affect my ability to work?

One of my patient’s responses was noteworthy—in a rich Irish brogue: “Jesus Christ, I’m going to go back to drinking and smoking.”

When a man is told he has the “C-word”—one of the most loaded words in the English language—his reflex response is often to want immediate action against such a potentially life-altering diagnosis that is capable of stealing precious time from the days he is granted on this planet. However, immediate action is neither desirable nor necessary since in most cases “time is on your side” and it is important to allow a sufficient period of time to become educated and informed about prostate cancer and to process the diagnosis and the various treatment options.

One’s reaction will continue to evolve over time and most men will experience discrete emotional stages, similar to those experienced during the process of grieving (do you remember Elisabeth Kubler Ross and her stages of grief?). Shock is followed by anger, distress, anxiety, irritability, sadness and perhaps depression and feelings of powerlessness.  During this period, it is not uncommon to feel overwhelmed, lethargic and fatigued.  Many men experience difficulty concentrating, insomnia and lose interest in sex.

Ultimately, one comes to terms with and accepts the reality of the diagnosis, particularly with the realization that most men with prostate cancer will go on to live long and healthy lives with fewer side effects than in previous years because of advances in treatment. Although prostate cancer can be a deadly disease for some men, it has one of the highest survival rates of any cancer, with a 99% 5-year and a 96% 15-year survival rate.

What exactly is cancer?

Cancer is 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 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.

The first goal in prostate cancer is for early detection–before the events described in the preceding paragraph have a chance to occur–to enable cure of the disease.  The second goal is to accurately ascertain risk to predict the potential for aggressiveness and severity, since every cancer has a unique biological behavior.  Using risk assessment tools, any given prostate cancer can be categorized into one of five risk categories with a  determination made of who has aggressive disease that requires treatment and who has indolent disease that can be managed with surveillance.  The third goal is cancer control with preservation of urinary and sexual function in those who have been determined to have potentially aggressive disease that merits 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

Preview of 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

The Prostate Gland: Man’s Center of Gravity

February 16, 2019

Andrew Siegel MD  2/16/19

This entry can be considered to be “Prostate 101: Introductory Level.”  The prostate gland is a mysterious male reproductive organ that can be a source of curiosity, anxiety, fear and potential trouble. Since this gland is a midline organ nestled deep within the pelvis, I like to think of it as man’s “center of gravity.”  

Center_of_pressure_in_relation_to_center_of_gravity_while_off_balance

Attribution: Jasper.o.chang [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)%5D; image unmodified; COG = center of gravity, COP = center of pressure

Where exactly is the prostate gland?

The prostate gland is located behind the pubic bone and is attached to the bladder above and the urethra below. The rectum is directly behind the prostate (which permits access for prostate exam).  The prostate is situated at the crossroads of the urinary and reproductive tracts and completely envelops the urethra, enabling its many ducts to drain into the urethra. However, this necessary anatomical relationship between the prostate and the urethra can potentially be the source of problems for the older male. With the aging process, this gland gradually enlarges and as it does so, this prostate enlargement can compress and obstruct the urethra, giving rise to bothersome urinary symptoms.  Note normal prostate on left and enlarged prostate on right in image below.

Benign_prostatic_hyperplasiaImage above, public domain, Wikipedia, illustrator unknown

What is the prostate, what purpose does it serve, and how does it function?

The prostate is a male reproductive gland that functions to produce prostate fluid, a nutrient and energy vehicle for sperm. The prostate consists of glandular and fibro-muscular tissue enclosed by a capsule of collagen, elastin and smooth muscle. The glandular tissue contains the secretory cells that produce the prostate fluid.

Semen is a “cocktail” composed of prostate fluid mixed with secretions from the seminal vesicles and sperm from the epididymides. The seminal vesicle fluid forms the bulk of the semen. The seminal vesicles and vas deferens (tubes that conduct sperm from testes to prostate) unite to form the ejaculatory ducts.

Prostate And Seminal Vesicles

At the time of sexual climax, prostate smooth muscle contractions squeeze the prostate fluid through prostate ducts at the same time as the seminal vesicles and vas deferens contractions squeeze seminal fluid and sperm through the ejaculatory ducts. These pooled secretions empty into the urethra (channel that runs from the bladder to the tip of the penis).  Rhythmic contractions of the superficial pelvic floor muscles result in the ejaculation of the semen.

What are the zones of the prostate gland?

The prostate gland is comprised of different anatomical zones. Most cancers originate in the “peripheral zone” at the back of the prostate, which can be accessed via digital rectal exam. The “transition zone” surrounds the urethra and is the site where benign enlargement of the prostate occurs. The “central zone” surrounds the ejaculatory ducts, which run from the seminal vesicles to the urethra.

Prostate Zones

Curious Facts About the Prostate

  • The prostate functions to produce a milky fluid that serves as a nutritional vehicle for sperm.
  • Prostate “massage” is sometimes done by urologists to “milk” the prostate to obtain a specimen for laboratory analysis.
  • The prostate undergoes an initial growth spurt at puberty and a second one starting at age 40 or so.
  • A young man’s prostate is about the size of a walnut, but under the influence of aging, genetics and testosterone, the prostate gland often enlarges and constricts the urethra, which can cause annoying urinary symptoms.
  • In the absence of testosterone, the prostate never develops.
  • The prostate consists of 70% glands and 30% muscle. Prostate muscle fibers contract at sexual climax to squeeze prostate fluid into the urethra.  Excessive prostate muscle tone, often stress-related, can give rise to the same urinary symptoms that are caused by age-related benign enlargement of the prostate.
  • Women have a female version of the prostate, known as the Skene’s glands.

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

3-minute video trailer for Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

 

 

PROSTATE CANCER 20/20: A Practical Guide To Understanding Management Options For Patients And Their Families

January 26, 2019

Andrew Siegel MD    1/26/2019

NEW BOOK!

front 3d smallFor the past year I have been busy writing a book on prostate cancer geared for newly diagnosed patients and their families. It originated in the form of a 50-page monograph  that I crafted about a decade ago, conceived out of frustration from the lack of availability of a streamlined, practical, accessible and trustworthy medical resource to help patients and their families navigate through the formidable process of prostate cancer diagnosis and management. The manual proved to be beneficial for my urology patients and was reprinted in 2011.

In early 2018, with few copies remaining and time for a reprint, I recognized that since the previous iteration there had been an unprecedented number of advances in prostate cancer diagnosis and management. These included improvements in screening, increasingly sophisticated imaging techniques, the development of genomic and genetic testing, the availability of an array of new medications, continued technical advances in surgical, radiation and focal therapies and the blossoming of the era of “active surveillance.”

Because of the need for a major content update, I decided to expand the monograph into a more comprehensive format that could be of value not only to the patients in my urology practice, but also to any man confronting the challenges of a prostate cancer diagnosis. I aimed to stay true to my original goals of providing a concise, straightforward and easily understandable resource.

I had numerous medical colleagues help me to bring this book to fruition: my robotic urology partners (Drs. Wright, Christiano, Lovallo, Ahmed, Esposito, Goldstein, Lanteri),  radiation oncologists (Dr. Harrison and Dr. Gejerman), medical oncologists (Dr. Alter and Dr. Orsini), a urologist with expertise in high intensity focused ultrasound (Dr. Grunberger), a radiologist with expertise in prostate MRI (Dr. Waxman) an anatomical pathologist (Dr. Peters), a sexual educator who is the president of the E.D. foundation (Paul Nelson) and a pelvic floor physiotherapist (Niva Herzig).

Because most patients with prostate cancer have an excellent prognosis, the long-term consequences of the disease are often, in fact, the side effects of treatment.  Therefore, I considered it vital to provide in-depth information on the most common complications following treatment, namely sexual dysfunction and urinary incontinence, quality of life issues that are sometimes given short shrift or neglected in the patient education process. Furthermore, I elected to cover the important topic of bone health, which can be compromised by prostate cancer itself, as well as by some of the treatments for the disease.  Perhaps the most challenging area to cover was castrate resistant prostate cancer, made complex by the profusion of exciting new treatment options.

The title of the book— PROSTATE CANCER 20/20: A Practical Guide To Understanding Management Options For Patients And Their Families—is the same as that of the preceding monograph with the exception of the addition of “20/20.”  I did so to specify the year that looms in the near future, signifying the up-to-date content, and secondly to refer to “20/20” vision, the clarity and perspective that I wish to impart.

Along with my professional relationship with prostate cancer, I also have a personal relationship with it. In 1997, the senior partner in my urology group practice—my father—was diagnosed with prostate cancer.  The news was shocking to me and I clearly remember the day of diagnosis and the long run I went on to help me process it. Fortunately, he was successfully treated with an open radical prostatectomy and today is a thriving octogenarian.  Despite this, the emotional events of the day of his surgery, my interaction with his surgeon, his time in the hospital, the drive home on his day of discharge, and my removal of his surgical drain, skin staples and catheter will be forever seared into my memory.

Every case of prostate cancer is unique and has a variable biological behavior, which creates the need for treatment that is individualized and nuanced. The bewildering array of management options available can cause a great deal of confusion for the individual (and his family, friends and others who support him) grappling with trying to determine how best to be treated. My intent of the book is to provide knowledge and information to help guide the reader and his loved ones through his therapeutic journey, reviewing the advantages and disadvantages of each management option in as impartial a means as is possible. Being informed empowers the prostate cancer patient to be actively involved as a participant in decisions about his care, which enables making the choice of the best option in order to minimize decisional conflict and regret.

Prostate Cancer 20/20 preview

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.

Andrew Siegel MD Amazon author page 

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