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September Newsletter 2014
Dr. Martha B. Boone

SEPTEMBER IS PROSTATE CANCER
AWARENESS MONTH!

Dr. Boone's surgery was very successful!!  She is coming back part time September 22 and full time September 26,2014.

While I have been home recovering from my recent surgery, I have been reading articles on prostate cancer. As a board certified urologist, I advise many men about PSA screening and about prostate cancer care.
PSA (prostate specific antigen) screening for prostate cancer is a very confusing matter for most of my patients. I am attempting to educate you about the issues behind the controversy of PSA screening and to give you , my “opinion” based on 29 years of taking care of men and reading the world’s literature on this topic and attending national and international meetings where the topics are discussed by the world’s leading researchers.

What is a PSA test? It is a blood test that detects the protease prostate specific antigen which can be produced in prostate cancer, prostate infection, and non-cancerous (benign) prostate diseases. It has been FDA approved for over 2 decades.

Who thinks it is a bad test and should not be used for screening?  The United States Preventive Services Task Force.  (the government)

Why do they not recommend the test?  There are many groups studying prostate cancer. The government studies it from a public health standpoint. They look at large populations and determine whether there is a high statistical chance that any particular test would benefit a population of men.
I believe that their work was very flawed for three reasons:1)There was not one single person in their study group who was a recognized prostate cancer expert 2)They did not have an adequate sample of high risk people in their study. (African American men, and men with first degree relatives with prostate cancer) 3)Also, their patients who were supposed to not be getting PSA screening were often being screened and treated in the private sector. So, they were not true “controls”, meaning men who had no PSA screening.

The USPSTF has the job of trying to figure out from population dynamics, the best utilization of our healthcare dollars. It is an important job, but has NOTHING to do with an individual patient. Telling a man that he has a 1/1000 chance of getting prostate cancer, means nothing to him if he is the one who has it.  So, numbers are great, but I treat men! I believe that the United States Preventive Services Task Force has done a huge disservice to men by taking the stance that men should not be screened for prostate cancer.

Over my 29 years of caring for men, I have seen that nearly all men will have some evidence of prostate cancer in their prostate if they live long enough. 80% of 80 year old men will have some prostate cancer in their gland. I have also observed that prostate cancer is a far more deadly disease in African American men and I have observed that prostate cancer is more deadly when diagnosed at a younger age. (<55)

I read the European literature, which has predominantly men of Caucasian descent in the studies. My review of their population who was screened using PSA showed a >22% REDUCTION in prostate cancer deaths!  It is hard to find that data in the United States literature, as our population has historically been screened using PSA. (We do not have large numbers of men who have never had any prostate cancer screening in our country)

Obviously, what should concern all of us is the possibility for over diagnosis and over treatment. The Hippocratic Oath says, “First, Do No Harm!” So, it behooves both the patient and the doctor to pause and consider the benefits and the risks of widespread screening of prostate cancer with PSA testing.
What “harm” could come from PSA screening? 1) Emotional stress. Some men are very stressed in knowing that their PSA is not normal. 2) Pain from prostate biopsy 3) Infection from prostate biopsy (this happens in 4/100 men. 4) Having surgery, radiation, proton therapy, HIFU therapy that could possibly cause complications 5) Expense of treatment

So, when the world’s experts sat down to review the world’s literature and come up with recommendations, what did they decide?
  1. If you are not African American and have no symptoms and have no family members with prostate cancer, you do NOT need screening before age 40.
  2. If you are age 40-54 and are not African American and you have no symptoms and no family members with prostate cancer, you can take a “flexible approach” to screening.  This means that you and your doctor can make the decision to screen/not screen based on your values and preferences.
  3.  The highest level of evidence for screening using PSA came from the 55-69 years old age group. Nobody should be screened without their permission and each man should understand the risks/benefits of screening.
  4. After age 70, screening with PSA is NOT recommended, unless the man is particularly healthy and expected to live longer than 15 years.
These recommendations are based on experts who treat prostate cancer every day, but are from statistical analysis.
 
My recommendations to my patients are slightly different:

The PSA test is imperfect, as are ALL cancer markers. But, it is better than any other test, currently. I have read about all other cancer markers for prostate cancer and am still convinced that the PSA test is superior.

I would like to see all of my male patients get a baseline PSA test while in their 40’s. If you have a test that is <1 in your 40’s you are in the low risk group and could wait until after 50 to be checked again. (IF you have no family members with prostate cancer and you are not African American) Your insurance company is very unlikely to be willing to pay for this test. So, you might be out of pocket $100. Lab Corp, Quest and Any Lab can do this test for you. I would like to have a baseline rectal exam and PSA on all of my male patients over 40. Even though the chance of detecting any abnormality is extremely low, I would like to have the baseline. When you show up at 55 with a brother who has been diagnosed with prostate cancer, wouldn’t it be worth $100 to know what your PSA was? If it used to be 1 and is now 3, we would certainly want you to consider biopsy. If it was 1 and is now 1, we would be much less worried.  Without this information, we have nothing with which to compare.

For reasons that are very poorly understood, prostate cancer behaves very poorly in African American men. It is a MUCH worse disease in this population. Very little study has been done on this topic. But, all urologists know that the African American community is at much greatly risk for the worse forms of prostate cancer and must be monitored more carefully.

The first man that I ever saw die of prostate cancer was a very lovely 52 years old African American man.

He was the devoted father of 3, a committed husband, and a valuable member of the New Orleans community. He had NO symptoms, until the prostate cancer was all over his body. I first met him and his wife in the emergency room at Tulane medical center. He had some mild abdominal pain. When I put my hand to his abdomen, it was hard. His entire abdomen was full of prostate cancer. Despite our best efforts, he was dead in less than 6 weeks. He will be forever imprinted in my mind. Could he have been saved if he had PSA testing? Only God knows the answer to that question. But, when I hear the government say that “nobody needs PSA screening”, I think of this man, his wife and his children. Would a $100 test have saved him?

So, my discussion of prostate cancer is not fully based on scientific facts. It is based on being the one who sits in front of a man and his family and delivers the good/bad news. I have faces to put with those numbers and to say that I am “biased” is an understatement. I DON’T WANT ANY MAN TO DIE OF PROSTATE CANCER!! The numbers that are acceptable to the government are not acceptable to me as a urologist.

Dr. Martha Boone’s approach:

If you are not African American and you have NO family members with prostate cancer and your PSA is less than one in your 40’s, you can be rechecked at 50-52. If you fall into the low risk group, you could be checked every 1-2 years.

If you are African American or you have a relative with prostate cancer, I’d like for you to have a PSA and rectal exam every year.

PLEASE REMEMBER THAT BEING SCREENED IS VERY DIFFERENT FROM DECIDING TO HAVE A BIOPSY AND DECIDING TO HAVE TREATMENT. Being screened is just trying to determine your risk. Deciding whether to have a biopsy and certainly deciding treatment is a completely different set of decisions.

I am proposing a flexible approach based on the individual man and his doctor. No two men are exactly alike and blanket statements of how to use screening tests are going to cause unnecessary deaths.

IN MY READING OF THE WORLD’S LITERATURE, IT APPEARS TO ME THAT THERE IS A 25% INCREASED RISK OF PROSTATE CANCER DEATH IN MEN WHO ARE NOT SCREENED.
I would like to say a few words about other tests that you might have seen in the newspaper. I use the prostate health index (PHI) in men who are >50 years old with a PSA between 4 and 10 and no prostate nodule on digital rectal exam. It costs about $150 at the lab and can save some men from biopsy if totally normal.

The urine test PCA3 has shown no benefit over PSA in routine screening. I have used it with success when evaluating a man with an elevated PSA and a prior normal biopsy. If perfectly normal, this test can sometimes save a man from the second biopsy.

On a very positive note, prostate cancer treatment has come a long way. I remember being a young urologist seeing 100 men a day in a VA medical center clinic and feeling that I had little to offer. The younger men (48-62) who could really benefit from early detection were not coming in. I mean, really, what man wants a rectal exam? I saw hundreds of men with advanced stage prostate cancer and there was little that we could do, except provide palliative care.

Those days are over and we have a great prostate cancer support system in Atlanta. Anything that any man could desire can be found here.

I’ve given you the “facts”. And I’ve given you my “opinion.”

I hope it helps.

Martha B Boone MD

September 2014
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