Archive for September, 2008.

A man comes in with symptoms of prostatism

Posted on September 29th, 2008 by Canadian Health in Cancer screening

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A man comes in with symptoms of prostatism. What about prostate specific antigen testing then? Let’s say you decided that you are not necessarily offering testing to all of your patients. But if a man comes in with prostatism, what should you do? Well, I’m sure all of you know that if you referred that patient to a urologist, which is becoming less frequent, at least in my practice, they would do prostate cancer screening on a careful basis. But if you are sitting with a man and you decide you are going to start them on an alpha blocker therapy, titran, should you also, as part of your evaluation, include a PSA test? The PSA in men with benign prostatic hypertrophy is much less, the specificity drops. So you are going to deal with more false positive tests in this population. In the AHCPR guidelines for how should you work up men with prostatism, they do not recommend PSA testing. I happen to do it. I do it especially with my patients saying … let me tell you the discussion that I do, and the real point of this discussion is; there are a lot of patients who are going to develop these problems. It’s unclear, should we screen them. You are supposed to elicit the patient values as to whether you should do the test or not. My discussion with men is to say, “There’s this test I can do that can find out whether you have prostate cancer. If you have a positive test, I’m not sure you’ve got it, but what I would recommend you undergo is a biopsy to see if you have the disease. If you undergo a biopsy and it is positive, it is still not clear whether we should do anything about it. What we do is we look at it under the microscope, and it looked like an angry tumor, we would recommend either radiation therapy or surgical resection. But I’ll tell you, if it looks sort of calm and is just sitting there, we might recommend that we do nothing at all. Now how would you feel if we went through this workup and I looked at you and said, ‘the best treatment may be to do nothing, or to do x-ray therapy, or to do surgery?’ is this still something you want to do?” And that’s actually my way out of the discussion. A surprising number of men still say, “I’d rather know than not know.” A surprising number of men say, “Never mind. Let’s not do it.” But I actually do that discussion with all men. Canadian viagra online.
With my patients who are women between the ages of 40 and 50, I say, “The American Cancer Society recommends that you undergo a mammogram every one to two years. However, the data I read suggested that it won’t necessarily help you live longer by doing that. If you were at standard risk for breast cancer, this decision is really up to you. What would you like to do?” And you need to document that you had that kind of discussion. Because, by the way, you in risk management, meaning malpractice hell, if you at least have a document of such discussion with the patient.

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Prostate cancer. Cancer screening

Posted on September 12th, 2008 by Canadian Health in Cancer screening

Prostate cancer. The American Cancer Society, which is, by the way, in the business of finding cancer, it has a bias that way – recommends annual screening beginning at the age of 50 for all men. Screening should include digital rectal examination and prostate specific antigen testing. Screening should begin at the age of 40 if you are taking care of an African-American, or if you are taking care of a man who has a positive family history of prostate cancer. These are the recommendations by the U.S. Preventative Health Services task force; they also happen to be the recommendation by the American College of Physicians; that routine screening for prostate cancer with digital rectal exam, or serum tumor markers, or transrectal ultrasound is not recommended. Now, if screening is to be done … it’s interesting, the U.S. Preventative Health Services task force book says, it’s not indicated and there’s no data to support doing it. But if you are going to do it, here’s how you do it. If you are going to do it, use those tests, and you should limit the test to men who you expect to have a life expectancy of greater than 10 years. And at the moment, that means men up to the age of 74. Cheap levitra licensed pharmacy.
The burden here, is it causes 35,000 to 40,000 deaths per year. There is substantial morbidity from the disease. There is a very – for patients who die from this, it can be very painful. Like breast cancer. The problem is that autopsy studies show that there is latent prostate cancer in 9 million men who are autopsied, on a population basis. The prostate specific antigen is a pretty sensitive test, but it may detect patients where the prostate cancer is of uncertain clinical significance. In other words, it may just be there and may not cause the patient a problem. One of the good things about screening for breast cancer is that it is very clear that we should do something about it when we find it. When we find prostate cancer, then we have to decide, is it going to do any thing to this patient or not? Which is a more difficult issue. Canadian pharmacy viagra.
There is no evidence, yet, to determine whether early detection and treatment improves survival. All of the studies that have been done so far, mostly from Sweden and Norway, show that there is no difference in survival in men who undergo surgical procedures or other procedure for prostate cancer, and men who are watched and observed conservatively. For well and moderately differentiated disease, the treatment so far offers little benefit over expectant management. The improved survival for men with early stage disease, that we are beginning to see, may be due to the fact that we are making an earlier diagnosis and we are actually changing the natural history of the disease by observing them longer.

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