Posts Tagged ‘PSA’

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

 

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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

 

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

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

 

Pre-Cancerous Prostate Conditions: What To Do?

April 7, 2018

Andrew Siegel MD 4/7/18

A prostate biopsy is usually done because of a PSA (prostate specific antigen) elevation, PSA acceleration, abnormal prostate exam or abnormal MRI. The biopsy results can range from benign to malignant. There is a gray area between these two extremes, consisting of pre-malignant conditions. What follows is a brief review of two pre-cancerous conditions, HGPIN and ASAP and how to minimize the risk of developing prostate cancer. 

Basic Prostate Histology 101

Microscopically, the prostate gland is organized like a tree with a major trunk draining each prostate lobe, 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), which is similar to a leaf at the end of a tree branch. Acini are lined by cells that secrete prostatic fluid, a nutrient vehicle for sperm that is an important component of semen. Each acinus is surrounded by a basement membrane that separates the cells that do the secreting from the surrounding structures.

Image below: benign prostate tissue

512px-Nodular_hyperplasia_of_the_prostate

Attribution: By Nephron (Own work) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)%5D, via Wikimedia Commons

Prostate biopsies are usually prompted by prostate cancer screening with PSA blood testing and digital rectal examination.  PSA elevation, PSA acceleration, abnormal prostate examination, abnormal prostate MRI, or follow up for prostate cancer or prostate precancerous conditions are the reasons why biopsies are performed.  There are four possible pathological outcomes from undergoing a prostate biopsy:

  1. benign
  2. HGPIN (High Grade Prostate Intra-Epithelial Neoplasia)
  3. ASAP (Atypical Small Acinar Proliferation)
  4. prostate cancer

What is HGPIN?

HGPIN is an acronym for High Grade Prostate Intra-Epithelial Neoplasia. The incidence of HGPIN between 0.6% and 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 other 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 (unifocal 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 repeat biopsy should be done in 6-12 months, with focused sampling of identified areas and adjacent sites. The more cores containing HGPIN on initial prostate biopsy, the greater the likelihood of cancer on subsequent biopsies. The 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. The incidence of ASAP ranges between 5% and 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 approximately 40%. All men with ASAP should undergo re-biopsy within 3 to 6 months, with focused sampling of identified areas and adjacent sites.

 Measures to Reduce Risk of Prostate Cancer

  1. Maintain a healthy weight, as obesity has been 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 metastasis and death are increased about 1.3-fold in men with a BMI of 30-35 and about 1.5-fold in men with a BMI > 35. Furthermore, carrying the burden of extra weight increases the complication rate following treatments for prostate cancer.
  2. “Eat food. Not too much. Mostly plants.” Eat realfood and avoid refined, over-processed, nutritionally-empty foods and be moderate with the consumption of animal fats and dairy. Processed meats and charred meats should be avoided.  A healthy diet should include whole grains and plenty of vegetables and fruits, particularly those that contain powerful anti-oxidants, vitamins, minerals and fiber. Vibrantly colorful fruits such as berries (strawberries, blackberries, blueberries and raspberries) contain abundant anthocyanins. Tomatoes and tomato products are rich in lycopenes. Cruciferous vegetables (broccoli, cauliflower, Brussel sprouts, kale and cabbage) and dark green leafy vegetables are fiber-rich and contain lutein and numerous healthy phytochemicals.  A healthy diet should include protein sources incorporating fish, lean poultry and plant-based proteins such as legumes, nuts, and seeds. Include fish that have anti-inflammatory omega-3 fatty acids, e.g., salmon, sardines, and trout. Healthy fats (preferably of vegetable origin, e.g., olives, avocados, seeds and nuts) are preferred.  An ideal diet that is both heart-healthy and prostate-healthy is the Mediterranean diet.
  3. Avoid tobacco and excessive alcohol intake. Tobacco use has been associated with more aggressive prostate cancers and a higher risk of progression, recurrence and death.
  4. Stay active and exercise on a regular basis. Exercise has been shown to lessen one’s risk of developing prostate cancer and to decrease the death rate of those who do develop it. If one does develop prostate cancer, he will be in better physical shape and have an easier recovery from any intervention necessary to treat the disease.  Exercise positively influences energy metabolism, oxidative stress and the immune system.  Aerobic exercise should be done at least every other day with resistance exercise two to three times weekly.  Pelvic floor muscle exercises benefit prostate health by increasing pelvic blood flow and lessening the tone of the sympathetic nervous system (the part of the nervous system stimulated by stress), which can aggravate lower urinary tract symptoms. Additionally, pelvic floor muscle exercises strengthen the muscles surrounding the prostate so that if one develops prostate cancer and requires treatment, they will experience an expedited recovery of urinary control and sexual function.
  5. Get checked out! Be proactive by seeing your doctor annually for a digital rectal exam and a PSA blood test. Abnormal findings on these screening tests are what prompt prostate biopsies, the definitive means of diagnosing prostate cancer. The most common scenario that 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.
  6. Finasteride and Dutasteride, commonly used to treat benign prostate enlargement and male pattern hair loss, reduce the risk of prostate cancer and may be used for those at high risk, including men with a strong family history or those with pre-cancerous biopsies. These medications lower the PSA by 50%, so anyone taking this class of meds will need to double their PSA to approximate the actual PSA. If the PSA does not drop, or if it goes up while on these meds, it is suspicious for undiagnosed prostate cancer. By shrinking benign prostate growth, these medications also increase the ability of the digital rectal exam to detect an abnormality.

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.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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

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

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

6 Ways To Reduce Your Risk Of Prostate Cancer

May 13, 2017

Andrew Siegel MD  5/13/17

Prostate cancer is incredibly common– one man in seven will be diagnosed with it in his lifetime–with average age at diagnosis mid 60s. In 2015, an estimated 221,000 American men were diagnosed and 28,000 men died of the disease.  Although many with low-risk prostate cancer can be managed with careful observation and monitoring, those with moderate-risk and high-risk disease need to be managed more aggressively. With proper evaluation and treatment, only 3% of men will die of the disease. There are over 2.5 million prostate cancer survivors who are alive today.

Factoid: The #1 cause of death in men with prostate cancer is heart disease, as it is in the rest of the population. 

finger 2

This is the index finger of yours truly; observe the narrow digit, a most desirable feature for a urologist who examines many prostates in any given day.  The digital rectal exam of the prostate is a 15-second exam that is at most a bit uncomfortable, but vital in the screening process and certainly nothing to fear.

Wouldn’t it be wonderful if prostate cancer could be prevented? Unfortunately, we are not there yet—but we do have an understanding of measures that can be pursued to help minimize your chances of developing prostate cancer.

Factoid: When Asian men–who have one of the lowest rates of prostate cancer– migrate to western countries, their risk of prostate cancer increases over time. Clearly, a coronary-clogging western diet high in animal fat and highly processed foods and low in fruits and vegetables is associated with a higher incidence of many preventable problems, including prostate cancer.

The presence of prostate cancer pre-cancerous lesions commonly seen on prostate biopsy—including high-grade prostate intraepithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP)—many years before the onset of prostate cancer, coupled with the fact the prostate cancer increases in prevalence with aging, suggest that the process of developing prostate cancer takes place over a protracted period of time. It is estimated that it takes many years—often more than a decade—from the initial prostate cell mutation to the time when prostate cancer manifests with either a PSA elevation, an acceleration in PSA, or an abnormal digital rectal examination. In theory, this provides the opportunity for intervention before the establishment of a cancer.

Measures to Reduce Your Risk of Prostate Cancer

  1. Maintain a healthy weight since obesity has been correlated with an increased prostate cancer incidence.
  2. Consume a healthy diet with abundant fruits and vegetables (full of anti-oxidants, vitamins, minerals and fiber) and real food, as opposed to processed and refined foods. Eat plenty of red vegetables and fruits including tomato products (rich in lycopene). Consume isoflavones (chickpeas, tofu, lentils, alfalfa sprouts, peanuts). Eat animal fats and dairy in moderation. Consume fatty fish containing omega-3 fatty acids such as salmon, tuna, sardines, trout and mackerel.  Follow the advice of Michael Pollan: “Eat food. Not too much. Mostly plants.”
  3. Avoid tobacco and excessive alcohol intake.
  4. Stay active and exercise on a regular basis. If you do develop prostate cancer, you will be in tip-top physical shape and will heal that much better from any intervention necessary to treat the prostate cancer.
  5. Get checked out! Be proactive by seeing your doctor annually for a digital rectal exam of the prostate and a PSA blood test. Abnormal findings on these screening tests are what prompt prostate biopsies, 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 Factoid: 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. 

  1. Certain medications reduce the risk of prostate cancer by 25% or so and may be used for those at high risk, including men with a strong family history of prostate cancer or those with pre-cancerous biopsies. These medications include Finasteride and Dutasteride, which are commonly used to treat benign prostate enlargement as well as male pattern hair loss. These medications lower the PSA by 50%, so any man taking this class of medication will need to double their PSA in order to approximate the actual PSA. If the PSA does not drop, or if it goes up while on this class of medication, it is suspicious for undiagnosed prostate cancer. By shrinking benign prostate growth, these medications also increase the ability of the digital rectal exam to detect an abnormality.

Bottom Line: A healthy lifestyle, including a wholesome and nutritious diet, maintaining proper weight, participating in an exercise program 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.  Prevention and early detection are the key elements to maintaining both quantity and quality of life. 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as 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 that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

 

Prostate Cancer Update 2017: A More Nuanced Approach

December 3, 2016

Andrew Siegel MD  12/3/2016

prostate_cancerAttribution of above image: Blaus (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)%5D, via Wikimedia Commons

It was not so long ago that all prostate cancers were lumped together, the thought being that a cancer is a cancer and best served by surgical removal. Consequently, with the best of intentions, some unnecessary surgical procedures were performed that at times resulted in impaired sexual function, poor urinary control, and unhappy patients.

Fortunately, urologists have become wiser, recognizing that individual prostate cancers are unique and that a nuanced approach is the key to proper management. Some prostate cancers are so unaggressive that no cure is necessary, whereas others are so aggressive that no treatment is curative. One thing is for certain—we have vastly improved our ability to predict which prostate cancers need to be actively treated and which can be watched.

The Challenge Of Diagnosing Prostate Cancer

The vast majority of patients who have undiagnosed prostate cancer have NO symptoms—no pain, no bleeding, no urinary issues, no anything. The possible diagnosis of prostate cancer is usually entertained under three circumstances: when there is an elevated PSA (Prostate Specific Antigen) blood test; when there is an accelerated PSA (when the change in PSA compared to the previous year is considered to be too high); and when there is an abnormal prostate DRE (digital rectal exam)—a bump, lump, hardness, asymmetry, etc. The bottom line is that if you don’t actively seek prostate cancer, you’re not going to find it. When prostate cancer does cause symptoms, it is generally a sign of locally advanced or advanced prostate cancer. Therein lies the importance of screening.

The Dilemma Of Screening For Prostate Cancer

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.

How Is The Diagnosis of Prostate Cancer Made?

When the PSA is elevated or accelerated and/or if there is an abnormal prostate DRE in a reasonably healthy man with good longevity prospects, an ultrasound-guided prostate biopsy is in order. Obtaining tissue for an exam by a pathologist is the definitive and conclusive test. The biopsy will reveal if cancer is present and its location, volume and grade (aggressiveness).

If prostate cancer is present, it is useful to determine the risk potential of the prostate cancer (“risk stratify”) by classifying it into categories based upon the following:

T (Tumor) category

T1c: cancer found because of PSA elevation or acceleration with a normal DRE

T2a: palpable (that which can be felt on DRE) cancer of half or less of one side

T2b: palpable cancer of more than half of one side

T2c: palpable cancer of both sides

T3a: cancer outside prostate, but sparing the seminal vesicles (reproductive structures that store semen)

T3b: cancer involving seminal vesicles

T4: regional spread of cancer to sphincter, rectum, bladder or pelvic sidewall

Gleason Score

Dr. Gleason devised a system that grades prostate cancer by observing the cellular architecture of prostate cancer cells under the microscope. He recognized that prostate cancer grade is the most reliable indicator of the potential for cancer growth and spread. His legacy, the grading system that bears his name, provides one of the best guides to prognosis and treatment. The pathologist assigns a separate numerical grade ranging from 3 – 5 to each of the two most predominant patterns of cancer cells. The sum of the two grades is the Gleason score. The Gleason score can predict the aggressiveness and behavior of the cancer, with higher scores having a worse prognosis than lower scores.

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)

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

The significance of the Gleason Grade Group can be understood by examining the PSA five years after surgical removal of the prostate, correlating survival with the Grade Group. Ideally, after surgical removal of the prostate gland the PSA should be undetectable. A detectable and rising PSA after surgical removal is a sign of recurrent prostate cancer. The five-year rate of PSA remaining undetectable (biochemical recurrence-free progression) for surgical removal of the prostate in Grade Groups 1-5 is the following: 96%, 88%, 63%, 48%, and 26% respectively, indicating the importance of the grading system with respect to prognosis.

Number cores with cancer

Generally 12 – 14 biopsies are obtained, occasionally more. In general, the more cores that have cancer, the greater the volume of cancer and the greater the risk.

Percent of tumor involvement (PTI)

The percentage of any given biopsy core that has cancer present. In general, the greater the PTI, the greater the risk.

PSA

PSA is an excellent “tumor marker” for men with prostate cancer. In general, the higher the PSA, the greater the risk category.

PSA density

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

 

Risk Stratification For Prostate Cancer

Based upon the aforementioned parameters, 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 assignment is helpful in predicting the future behavior of the prostate cancer and in the decision-making process regarding treatment.

Very Low Risk: T1c; Gleason score ≤ 6; fewer than 3 cores with cancer; less than 50% of cancer in each core; PSA density < 0.15

Low Risk: T1-T2a; Gleason score ≤ 6; PSA < 10

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

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

 

Prostate Cancer Treatment

Prostate cancer treatment is based upon risk category and life expectancy and includes the following:

RALP (robotic-assisted laparoscopic prostatectomy): surgical removal of the prostate gland using robotic assistance

RT (radiation therapy): this can be used as definitive treatment or alternatively for recurrent disease after RALP or immediately following healing from RALP under the circumstance of adverse pathology report

ADT (androgen deprivation therapy): a means of decreasing testosterone level, since the male sex hormone testosterone stimulates prostate growth

AS (active surveillance): actively monitoring the disease with the expectation to intervene with curative therapy if the cancer progresses. This will involve periodic DRE, PSA, MRI, and repeat biopsy.

Observation: monitoring with the expectation of giving palliative therapy (relieving pain and alleviating other problems that may surface without dealing with the underlying cause)  if symptoms develop or a change in exam or PSA suggests that symptoms are imminent.

 

Prostate Cancer Treatment Based Upon Risk Stratification

Very Low Risk

< 10 year life expectancy: observation

10-20 years life expectancy: AS

> 20 years life expectancy: AS or RALP or RT

Low Risk

<10 years life expectancy: observation

>10 years life expectancy: AS or RALP or RT

Intermediate Risk

<10 years life expectancy: observation or RT + ADT 4-6 months

>10 years life expectancy: RALP or RT + ADT 4-6 months

High Risk

RALP or RT + ADT 2-3 years

Very High Risk:

T3b-T4: RT + ADT 2-3 years or RALP (in select patients) or ADT

Lymph node spread: ADT or RT + ADT 2-3 years

Metastatic disease: ADT

Bottom Line: Excluding skin cancer, prostate cancer is the most common cancer type in men, accounting for 26% of newly diagnosed cancers with men having a 1 in 7 lifetime risk. The median age of prostate cancer at diagnosis is the mid 60s and in 2015 there were 221,000 new cases per year, 27,500 deaths (the second most common form of cancer death, after lung cancer) and there are currently about 2.5 million prostate cancer survivors in the USA.  It is important to diagnose prostate cancer as early as possible in order to decide on the most appropriate form of management—whether it is surgery, radiation, or observation/monitoring. Risk stratification can help the decision-making process.

“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.”

Willet Whitmore, M.D.

(Dr. Whitmore served as chief of urology for 33 years at what is now Memorial Sloan-Kettering Cancer Center. He died of prostate cancer at age 78 in 1995.)

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

 

 

 

 

5 Things Every Woman Should Know About Her Man’s Pelvic Health

November 28, 2015

Andrew Siegel MD   11/28/15

4910841630_d096720d0d_o (1)

(Attribution: Pier-Luc Bergeron, A happy couple and a happy photographer; no changes made, https://www.flickr.com/photos/burgtender/4910841630)

Since this is Thanksgiving weekend and a broadly celebrated family holiday, I cannot think of a better time to blog about how wives/girlfriends/partners can help empower their men’s pelvic health.

  1. His Erections
  2. Prostate Cancer
  3. Bleeding
  4. Testes Lumps/Bumps
  5. Urinary Woes

 

Erectile Dysfunction: A “Canary in the Trousers”

If his erections are absent or lacking in rigidity or sustainability, it may just be the “tip of the iceberg,” indicative of more serious underlying medical problems. The quality of his erections can be a barometer of his cardiovascular health. Since penile arteries are tiny (diameter of 1-2 millimeters) and heart arteries larger (4 millimeters), it stands to reason that if vascular disease is affecting the penile arteries, it may affect the coronary arteries as well—if not now, then perhaps soon in the future. Since fatty plaque deposits in arteries compromise blood flow to smaller blood vessels before they do so to larger arteries, erectile dysfunction may be considered a genital “stress test.”

Bottom Line: If your man is not functioning well in the bedroom, think strongly about getting him checked for cardiovascular disease. His limp penis just may be the clue to an underlying more pervasive and serious problem.

Prostate Cancer

One in seven American men will develop prostate cancer in their lifetimes and most have no symptoms whatsoever, the diagnosis made via a biopsy because of an elevated or accelerated PSA (Prostate Specific Antigen) blood test and/or an abnormal rectal exam that reveals an asymmetry or lump. Similar to high blood pressure and glaucoma, prostate cancer causes no symptoms in its earliest phases and needs to be actively sought after.

With annual PSA testing, he can expect a small increase each year correlating with prostate growth. A PSA acceleration by more than a small increment is a “red flag.” The digital exam is simply the placement of a gloved, lubricated finger in the rectum to feel the size, contour and consistency of the prostate gland, seeking hardness, lumps or asymmetry that can be a clue to prostate cancer. It is not unlike the female  pelvic exam.

Bottom Line:  As breast cancer is actively screened for with physical examination and mammography, so prostate cancer should be screened for with PSA and digital rectal exam. In the event that prostate cancer is diagnosed, it is a treatable and curable cancer. Not all prostate cancers demand treatment as those with favorable features can be followed carefully, but for other men, treatment can be lifesaving.

Bleeding

Blood in the urine can be visible or only show up on dipstick or microscopic exam of the urine. Blood in the urine should also be thought of as a “red flag” that mandates an evaluation to rule out serious causes including cancers of the kidney and bladder. However, there are many causes of blood in the urine not indicative of a serious problem, including stones, urinary infections and prostate enlargement.

Blood in the semen is not uncommonly encountered in men and usually results from a benign inflammatory process that is usually self-limited, resolving within several weeks. It is rarely indicative of a serious underlying disorder, as frightening as it is to see blood in the ejaculate. Nonetheless, it should be checked out, particularly if it does not resolve.

Bottom Line: If blood is present when there should be none—including visible blood in the urine, blood stains on his undershorts or blood apparent under the microscope—it should not be ignored, but should be evaluated. If after having sex with your partner you notice a bloody vaginal discharge and you are not menstruating, consider that it might be his issue and make sure that he gets followed up.

Testes Lumps and Bumps

Most lumps and bumps of the testes are benign and not problematic. Although rare, testicular cancer is the most common solid malignancy in young men, with the greatest incidence being in the late 20s, striking men at the peak of life. The excellent news is that it is very treatable, especially so when picked up in its earliest stages, when it is commonly curable.

A testicular exam is a simple task that can be lifesaving. One of the great advantages of having his gonads located in such an accessible locale—conveniently “gift wrapped” in the scrotal satchel—is that it makes them so easy to examine. This is as opposed to your ovaries, which are internal and not amenable to ready inspection. This explains why early testes cancer diagnosis is a cinch as opposed to ovarian cancer, which most often presents at an advanced stage. In its earliest phases, testes cancer will cause a lump, irregularity, asymmetry, enlargement or heaviness of the testicle. It most often does not cause pain, so his absence of pain should not dissuade him from getting an abnormality looked into.

Your guy should be doing a careful exam of his testes every few weeks or so in the shower, with the warm and soapy conditions beneficial to an exam. If your man is a stoic kind of guy who is not likely to examine himself, consider taking matters into your own hands—literally: At a passionate moment, pursue a subtle, not-too-clinical exam under the guise of intimacy—it may just end up saving his life.

Bottom Line: Have the “cajones” to check his cajones. Because sperm production requires that his testes are kept cooler than core temperature, nature has conveniently designed mankind with his testicles dangling from his mid-section. There are no organs in the body—save your breasts—that are more external and easily accessible. If your man is not willing to do self-exams, at a moment of intimacy do a “stealth” exam under the guise of affection—it just might be lifesaving.

Urinary Woes

Most organs shrink with the aging process. However, his nose, ears, scrotum and prostate are the exceptions, enlarging as he ages. Unfortunately, the prostate is wrapped precariously around the urinary channel and as it enlarges it can constrict the flow of urine and can cause a host of symptoms. These include a weaker stream that hesitates to start, takes longer to empty, starts and stops and gives him the feeling that he has not emptied completely. He might notice that he urinates more often, gets up several times at night to empty his bladder and when he has to urinate it comes on with much greater urgency than it used to. He might be waking you up at night because of his frequent trips to the bathroom. Almost universal with aging is post-void dribbling, an annoying after-dribble.

Bottom Line: It is normal for him to experience some of these urinary symptoms as he ages. However, if he is getting up frequently at night, dribbling on the floor by the toilet, or has symptoms that annoy him and interfere with his quality of life, it is time to consider having him looked at by your friendly urologist to ensure that the symptoms are due to benign prostate enlargement and not other causes, to make sure that no harm has been done to the urinary tract and to offer treatment options.

Wishing you the best of health and a wonderful Thanksgiving weekend,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

Her Breasts and His Prostate…So Similar, So Mysterious

July 18, 2015

Andrew Siegel MD  7/18/15

prostate breast

(Thank you, Wikimedia, for above image)

The female breasts and the male prostate are both sources of fascination, curiosity, and fear. Hidden deep in the pelvis at the crossroads of the male urinary and reproductive systems, the prostate is arguably man’s center of gravity. On the other hand, the breasts—with an equal aura of mystery 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, curiously an erogenous zone as well as a feeding zone.

Interestingly enough, the breasts and prostate share much in common, both serving important “nutritional” roles. Each functions to manufacture a milky 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, which demand intense nutrition to support their arduous  marathon journey traversing the female reproductive tract.

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 female sex hormone estrogen and after menopause when estrogen levels decline, the glandular tissue withers, with the fatty tissue predominating.

The prostate—on the other hand—is made up of glandular tissue that produces prostate “milk,” and ducts that empty this fluid into the urethra at the time of sexual climax. At ejaculation the prostate fluid combines 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 male 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 the prostate fluid is via stimulation of the erect penis, with the release of semen and its prostate fluid component at the time of ejaculation.

Both the breasts and prostate can be considered to be reproductive organs since they are vital to nourishing infants and sperm, respectively. At the same time, they are sexual organs. The breasts can be thought of as accessories with 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 climax is the means of accessing the prostate’s reproductive function.

Both the breasts 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, prostate cancer is the most common cancer in men (accounting for 26% of newly diagnosed cancers with men having a 1 in 7 lifetime risk) and breast cancer is the most common cancer in women (accounting for 29% of newly diagnosed cancers with women having a 1 in 8 lifetime risk). Both 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 medication, e.g., Tamoxifen and Lupron, respectively. Both breast and prostate cancer incidence increase with aging. The median age of breast cancer at diagnosis is the early 60’s and there are 232,000 new cases per year, 40,000 deaths (the second most common form of cancer death, after lung cancer) and there about 3 million breast cancer survivors in the USA. The median age of prostate cancer at diagnosis is the mid 60’s and there are 221,000 new cases per year, 27,500 deaths (the second most common form of cancer death, after lung cancer) and there are about 2.5 million prostate cancer survivors in the USA.

Both breast and prostate cancer are often detected during a screening examination before symptoms have developed. Breast cancer is often picked up via mammography, whereas prostate cancer is often identified via an elevated or accelerated PSA (Prostate Specific Antigen) 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 with 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. Imaging tests used in the diagnosis and evaluation of both breast and prostate cancers are similar with both ultrasonography and MRI being very useful. Treatment modalities for both breast and prostate cancer share much in common with important roles for surgery, radiation, chemotherapy and hormone therapy.

In a further twist to the relationship between breast and prostate cancer, a recent study showed that women with close male relatives with prostate cancer are more likely to be diagnosed with breast cancer. Compared to women with no family history of breast or prostate cancer, those with a family history of both were 80% more likely to develop breast cancer.

Breast and Prostate Cancer Myths and Facts

“Only old people get breast or prostate cancer.

Fact: 25% of women with breast cancer develop it before age 50, whereas less than 5% of men with prostate cancer develop it before age 50; however, many men in their 50s are diagnosed with the disease.

“Men can’t get breast cancer and women can’t get prostate cancer.”

Fact: 1700 men are diagnosed with breast cancer with 450 deaths on an annual basis.  Women have structures called the Skene’s glands, which are the female homologue of the male prostate gland. On very rare occasions, the female “prostate” can develop cancer. The Skene’s glands are thought to contribute to “female ejaculation” at the time of sexual climax. 

“All lumps in the breast or prostate are cancer.”

Fact: 80% of breast lumps are due to benign conditions as are 50-80% of prostate “nodules.”  If an abnormality is found, further evaluation is necessary.  

“It’s not worth getting screened for breast cancer because of the USPSTF (United States Preventive Services Task Force) recommendation against routine screening mammography in women aged 40 to 49 years and against clinicians teaching women how to perform breast self-examination.  It’s not worth getting screened for prostate cancer because the USPSTF also recommended against prostate-specific antigen (PSA)-based screening for prostate cancer.”

Fact: In my opinion, the USPSTF has done a great deal of harm to public health in the USA with their recommendations. The goal of screening is to pick up cancers in their earliest stages at times when treatment is likely to be most effective. Not all cancers need to be treated and the treatment can differ quite a bit based upon specifics, but screening populations at risk is a no-brainer.  For breast cancer and prostate cancer–the most common cancer in each gender–it is important to screen aggressively to obtain the necessary information to enable doctors and their patients make sensible decisions, which are individualized and nuanced, depending on a number of factors.

The reader is referred to a terrific recent article in the NY Times concerning screening for prostate cancer: http://www.nytimes.com/2015/07/06/opinion/bring-back-prostate-screening.html

Wishing you the best of health,

2014-04-23 20:16:29

AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in your email in box go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: http://www.MalePelvicFitness.com.  Work in progress is The Kegel Fix: Recharging Female Sexual, Urinary and Pelvic Health.

Co-creator of Private Gym pelvic floor muscle training program for men: http://www.privategym.com—also available on Amazon.

The Private Gym program is the go-to means of achieving pelvic floor muscle strength, tone, power, and endurance. It is a comprehensive, interactive, easy-to-use, medically sanctioned and FDA registered follow-along exercise program that builds upon the foundational work of Dr. Arnold Kegel. It is also the first program designed specifically to teach men how to perform the exercises and a clinical trial has demonstrated its effectiveness in fostering more rigid and durable erections, improved ejaculatory control and heightened orgasms.

Prostate Cancer Screening: What’s New?

February 28, 2015

Andrew Siegel MD 2/28/15

The Dilemma

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.

The Buck Stops Here

Prostate biopsy (ultrasound guided) is the definitive and conclusive test for prostate cancer. An elevated PSA (Prostate Specific Antigen) blood test or an abnormal DRE (digital rectal exam) are the findings that typically lead to the recommendation for prostate biopsy.

What’s New In Prostate Cancer Screening?

The following are refinements in the screening process that can help make the decision about whether or not to proceed with a prostate biopsy, potentially sparing some from the need to undergo the biopsy and clearly indicating the need for biopsy in others.

  • Free PSA
  • PSA Velocity
  • PSA Density
  • PCA-3
  • Prostate MRI
  • 4K Score

Free PSA

PSA circulates in the blood in a “free” form, which it is unbound and a “complex” form, in which it is bound to a protein. The free/total PSA can enhance the specificity of PSA testing. The greater the free/total PSA, the greater the chances that benign enlargement of the prostate is the cause of the PSA elevation. In men with a PSA between 4-10, the probability of cancer is less than 10% if the ratio is greater than 25% whereas the probability of cancer is almost 60% if the ratio is less than 10%.

PSA Velocity

It is extremely useful to compare the PSA values from year to year. Under normal circumstances, PSA increases by only a small increment, reflecting age-related benign prostate growth. PSA acceleration at a rate greater than anticipated is a red flag that may be indicative of prostate cancer and is one of the most common prompts for undergoing biopsy.

PSA Density

There is a direct relationship between prostate size and PSA, with larger prostates producing higher PSA levels. PSA density (PSA/prostate volume) is the relationship of the PSA level to the size of the prostate. PSA density > 0.15 is a red flag that may be indicative of prostate cancer.

PCA-3 (Prostate Cancer Antigen-3)

PCA-3 is a specific type of RNA (Ribonucleic Acid) that is released in high levels by prostate cancer cells. Its expression is 60-100x greater in prostate cancer cells than benign prostate cells, which makes this test much more specific for prostate cancer than PSA.  PCA-3 is a urine test. The prostate is gently “massaged” via DRE to “milk” prostate fluid into the urethra. The first ounce of urine voided immediately after massage is rich in prostatic fluid and cells and is collected and tested for the quantity of PCA-3 genetic material present. Urinary levels of PCA-3 are not affected by prostate enlargement or inflammation, as opposed to PSA levels. PCA-3 > 25 is suspicious for prostate cancer.

Prostate MRI (Magnetic Resonance Imaging)

MRI is a high-resolution imaging test that does not require the use of radiation and is capable of showing the prostate and surrounding tissues in multiple planes of view, identifying suspicious areas. MRI uses a powerful Tesla magnet and sophisticated software that 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 classification Definition
I Most probably benign
II Probably benign
III Indeterminate
IV Probable cancer
V Most probably cancer

4Kscore Test

The 4Kscore Test 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 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 or Proscar 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.)

As of now, the test is not covered by insurance and costs $395 from the lab that performs it.

Bottom Line: Excluding skin cancer, prostate cancer is the most common cancer in men (accounting for 26% of newly diagnosed cancers with men having a 1 in 7 lifetime risk). The median age of prostate cancer at diagnosis is the mid 60’s and there are 221,000 new cases per year, 27,500 deaths (the second most common form of cancer death, after lung cancer) and there are currently about 2.5 million prostate cancer survivors in the USA.  It is important to diagnose prostate cancer as early as possible in order to decide on the most appropriate form of management–surgery, radiation, or observation/monitoring (the most common treatment pathways, although there are other options as well).  These refinements in the screening process can help urologists make the decision about whether or not to proceed with a prostate biopsy.  

 

Wishing you the best in health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the inbox of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health:available in e-book (Amazon Kindle, Apple iBooks, B & N Nook, Kobo) and paperback: http://www.MalePelvicFitness.com

Private Gym Male Pelvic Floor Muscle Training  Program: http://www.PrivateGym.com -available on Amazon as well as Private Gym website