On
PSAs
Prostatic specific antigen or PSA is a substance made by
normal prostate glands and is detectable in our blood. Any
disease that affects the prostate gland might cause it to
leak more PSA into the blood stream thereby elevating levels
above normal. The common causes of elevated PSA are acute
and chronic prostatitis, benign prostatic hyperplasia and
prostate cancer. All three are extremely common diseases.
Some 15 to 20 years ago, with the discovery of PSA and lab
tests to measure it, medicine got the bright idea of using
the PSA test to screen men for prostate cancer. This
approach seemed logical as the PSA test is relatively cheap,
the only significant direct side effect is a needle stick,
and prostate cancer is the number one cancer killer of
nonsmoking males. Hypothetically, a man gets prostate
cancer, his serum PSA concentration starts heading up, a
biopsy is performed on his gland proving the existence of
cancer in its early stages and thousands of men are thus
saved from certain death.
This is precisely how this huge distortion of reality was
sold. In the years since we have been screening men using
the PSA test, the mortality rate due to prostate cancer has
not changed with statistical certainty and the number of
surgical procedures men are subjected to has tripled at
considerable risk, morbidity, and expense. So, the only two
logical reasons to continue this farce are to 1.) pad
medicine’s bank account or 2.) to protect oneself from
perceived liability. Worse, none of this is new information.
The USPSTF has never recommended screening for prostate
cancer by measuring PSA but it didn’t take a strong stance
against it either saying that it could not find any
scientific evidence either for or against PSA screening. My
own opinion is that rendering thousands of men impotent,
incontinent or worse with prostate cancer treatment for no
overall benefit and at huge expense is reason enough to
recommend against PSA screening. AT LEAST DO NO HARM. Let’s
examine the reality and appreciate the complexity of this
issue as it is a compelling example of how complicated
medical issues can become and why the best approach is to
deal with each patient individually and tailor care to the
specifics of each case.
Prostate cancer is a very complex disease. If I biopsy the
prostates of 100 men over age 75 upwards of 50 will have
microscopic evidence of prostate cancer. Over 80% of these
individuals will never develop ANY symptoms related to their
prostate cancer; they will die eventually of other causes.
At this time, medicine has no good way of differentiating
between those whose disease is going to cause trouble and
those whose disease is not. So, from a liability and
financial perspective, most will recommend treatment- the
end result being that many men are permanently damaged or
worse for no overall benefit.
On the other hand, prostate cancer can be a vicious disease
(particularly in young individuals) and if caught early it
can be cured. So how can you diagnose it in time and
identify those who are going to get into trouble? The
problem with the PSA test is that it is neither specific nor
sensitive enough for prostate cancer screening. In other
words, too many other benign diseases cause PSA levels to
elevate and prostate cancer in its most curable state may
not elevate PSA levels at all. Just because you have a
normal PSA level does not mean you do not have prostate
cancer. Of the twelve cases that I diagnosed over the years
that stand a high probability of being cured, 9 had normal
PSA levels at the time of diagnosis. All were diagnosed at
routine physicals by my right index finger. Unless
specifically requested I only do PSA levels prior to biopsy
for prognostic value and I do the biopsies myself in my
office to the chagrin of the local urologic community. The
prostate biopsy is the definitive test for prostate cancer.
It is an easy office procedure that is well tolerated if
done properly. There are, however, two potentially serious
complications: bleeding and infection.
Because biopsy is invasive and has potentially serious
complications, it is difficult to envision it as a screening
test. Prostate cancer is most serious when diagnosed in the
fifth and sixth decades and there may be a prolonged
precancerous condition called cellular atypia detectable on
biopsy giving us a clue as to who needs closer follow up. I
would like to see a study performed wherein biopsies are
performed on a large population of men at ages 50, 55, and
60 comparing their overall mortality from prostate cancer to
that of an unscreened population and that of a population
screen by PSA levels only. Unfortunately, the data on using
rectal exams for prostate cancer screening is poor. There is
no question that prostate cancer can be detected this way
but there is extreme variability in skill and sensitivity
between examiners and even the best examiners will miss
cases because many cancers are deep within the gland and
can’t be felt. A new palpable abnormality in a prostate
gland is significantly more specific for prostate cancer
then a elevated PSA and should never be ignored unless the
patient is not a candidate for further treatment by virtue
of age, condition, or desire.
The two most important factors in determining who you are
going to treat aggressively are age and overall health. I
would go to town on a 50 year old marathon runner while I
might not even tell an 85 year old with a bad heart that he
has a problem. It is that big gray zone in the middle that
separates the great docs from the not so great ones. Each
case is different. Each patient comes to the table with
different expectations, desires, fears and background. Each
patient deserves an unbiased explanation of the realities of
his case so he can make an intelligent decision for himself.
This is not a dialogue you are likely to have successfully
with a urologist you have known for 30 minutes who brings
his own perception of liability and his financial welfare to
the table.
I know many great urologists who I would allow to operate on
me in a heartbeat but we are all human and many of the
pressures we are subjected to in medicine are not of our own
making. This conversation is best held with a personal
confidant who is comfortable in his relationship with the
patient and free of conflicts of interest, a personal
physician.
It is distasteful to say this but cancer has become a vast
greedy industry in this country. Just look at the marketing
on TV. That is money we spend on medical care being wasted
to improve the market share of hospitals and pharmaceutical
companies.
We do wonderful work in American medicine. We have wonderful
doctors, nurses, and other talented health care
professionals, but, taken in its entirety, our system
mistreats thousands of cancer patients yearly in the vain
attempt to cure incurable disease while inflicting extreme
suffering and expense. We do not differentiate between those
we know we can help, those we think we can help, those we
know we can’t help, and those we don’t have to help at all.
Much of the fault lies not with the medical system but
rather with the legal system the former is subjected to in
conjunction with the dysfunctional way people use both
systems.
We all know men who will swear that their lives were saved
by the PSA test and it's tempting to fall for that argument.
Although such a claim is possible in isolated cases, data on
large populations do not yet back up this allegation. It is
highly likely that just the opposite is true: that more men
are permanently damaged rather then are saved by the PSA
test.
Last week I did a physical on an 80 year old WW2 vet.
Unfortunately, I felt a small hard spot on the right lobe of
his prostate gland which was not there last year. After a
long heart to heart talk he decided against having it
biopsied.As of 2008
the US Government recommends against prostate cancer
screening in men over the age of 75.
Disease prevention
It is inarguable that not becoming afflicted with a disease
is superior to getting that disease and having to treat it
or succumbing to it. Most of the premature morbidity and
death that occurs in humans is entirely preventable. In
centuries past, the big killers were infectious disease,
war, and childbirth. In this society, our major killers are
cardio-vascular disease, cancer and accidents. Some 50% of
us die from cardio-vascular disease which remains the number
one killer of Americans. The vast majority of this is
preventable (and not by some modern medical miracle) by a
regimen of sensible diet, exercise, not smoking. Those that have high
blood pressure and high cholesterol will benefit from modern
medications. 30% of us die from cancer and as the number of
deaths from cardio-vascular disease drops this number is
going to rise because many that are saved from
cardio-vascular death will eventually die from cancer. Being
directly related to lung cancer, cancer of the oral cavity
and throat, cancer of the eosophagus and cancer of the
bladder, the number one cause of cancer deaths in Americans
remains the cigarette. A huge number of cancers are entirely
preventable by not smoking.
Fortunately, the smoking rate in this country has dropped
from almost 50% to less then 25% so the message is getting
through. There are other avoidable causes of cancer. Many
such as benzene, have been discovered and eliminated. Others
such as sun light and radiation can’t be eliminated but
their influence can be limited by avoiding overexposure.
What people need to understand about cancer is that it is a
NATURAL byproduct of our biology. Cancer’s existence is
preordained by nature and as such is never going to be
entirely preventable or even worth trying to cure in certain
instances.
We are all biologic machines with functional life spans
limited by the durability of our structures. If we are not
prematurely removed by disease, accident, or war we will all
eventually become old and disabled by functional loss. As
John F Kennedy said,” old age is a ship wreck.” How many 90
year olds can swing a baseball bat the way they did when
they were 20. The point is that it would be extraordinarily
inhumane to subject a wheelchair bound 90 year old to a
radical prostatectomy. The sad fact of our existence is that
there is always a point at which life is not worth
prolonging a reality that many, if not most, of us fail to
accept.
There is a huge disease prevention industry out there ready
to sell you anything that might remotely be of benefit to
your longevity. Shove it into a capsule, a bottle, and add a
fancy label. Throw in a little perverse marketing and bingo!
Instant profits. When the profits fall you take the same
stuff, put it in a different colored capsule, a bottle with
a new label and go at it again. Billions (if not trillions)
of dollars are wasted on this stuff yearly. While there are
some substances with proven benefit, for most the evidence
is marginal and indeed some are even harmful. Just recently
Ma Houng or Ephedra was removed from the market as it was
killing people!
Stein’s Axiom- If it is not perversely expensive and if
everyone you meet doesn’t know about it, it doesn’t work. If
you read about it in the back pages of some rag, forget it.
Consider Viagra, It costs $10 per pill. I challenge you to
find someone over the age of 18 who doesn’t know what Viagra
is. Yes, it works great. The Baby Boomers have now become
the Viagra Generation.
Dr Stein’s scheduled Health Maintenance for adults:
Yearly complete health history and examination starting at
age twenty.
Included are lifestyle assessment and counseling, obesity
assessment and counseling, Pap tests and breast exams in
women, testicular cancer education in males under 35, blood
lipid levels every fifth year, diabetes screening yearly,
Assessment of alcohol and drug use, Assessment of seatbelt
and helmet use, rectal exams in men from 40 on, mammograms
yearly from 40, Colon cancer screen in both genders starting
at 50
Dr Stein’s Advice:
Don’t Smoke
Average one hour of vigorous aerobic activity daily
Light weight lifting every other day
Avoid refined carbohydrates and high fat foods
Have fish twice weekly
Have a glass of red wine with dinner.
Take a well rounded multivitamin with at least 800mcg of
folic acid and no more than 200IU of vitamin E. Higher doses
of vitamin E may cause problems.
Take at least 2000IU of vitamin D3 daily
Take 1500mg glucosamine sulfate daily
Men over 50 take Saw Palmetto extract
Men and Women over 50 take 400mg of ibuprofen every morning
Chew two Tums with each meal at home
Wear your seat belts and protective helmets
Avoid unnecessary radiation both medical and natural.
Have a personal physician you can trust implicitly
Don’t forget your yearly exam
As of this time the above advice represents 90% of the
battle. The rest is pure luck.
I review the newest data frequently so the list will most
probably evolve over time.
Beware of Greeks bearing gifts.
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