October 2, 2012

My Doctors and Me: an Update. 1) Prostate Cancer

Over the past few weeks, I've had several regular checkups:

  • 1) with my urologist about my prostate cancer, 
  • 2) with my neurologist about my Parkinson's, and 
  • 3) with my doctor at Sibley Hospital's Pain Center about my back pain. 

As a result, I plan to write about these three areas over the next few days. Today: an update on my prostate cancer.

Prostate Cancer History
I learned about my prostate cancer in 1994. After reviewing options with my urologist (Dr. Nicholas Constantinople), I chose surgery. I had the prostatectomy at Sibley in early January, 1995. (I celebrated my 65th birthday in 1994 and retired after 40 years from BNA on December 31, 1964. So, the operation was my first use of Medicare.)

Post-operatve PSA tests indicated that some cancer cells remained. Fortunately, prostate cancer usually grows slowly, which proved true in my case. Since 1995, I've checked in with Dr. Constantinople every six months for both the "finger" and the PSA tests. That PSA reading increased slowly, from near zero in March, 1995, to over 4 in March, 2011.

Suddenly and surprisingly, the September, 2011 number spiked to 9.4! Urologists become concerned about a patient's prostate cancer when PSA readings double over the course of a year or two. Mine had more than doubled in just six months!

Dr. Constantinople didn't share my sense of panic. I was ready to hear him recommend hormone therapy or some other aggressive treatment. Instead he counseled, "Let's wait and see what the number is at your regular visit next March."

I was very relieved when the PSA test result this past March came in at 6.0. After these odd variations, I was anxious to see what my September visit would show.

September, 2012 Checkup 
The PSA test came in at 7.1. I was hoping for something a bit better, but in relaying the test result, Dr. Constantinople's assistant reported that the doctor had said this result was "in the normal range" for me.

I told my doctor that the big spike in September, 2011 had occurred less than a month after my car crash. I asked if the two incidents could be related. I wondered if the trauma of the crash -- and the resultant cracked vertebra -- might have played a part in the unusual PSA jump.

Dr. Constantinople said a connection was possible. Urologists and researchers have debated recently whether stress might contribute to elevated PSA readings.

So, I'm glad there's no hormone therapy or other aggressive treatment in my future. Maybe if I can resolve the back pain, the reduced stress level will yield a good PSA number at my checkup next March.

Dr. Constantinople on Recommendations to Cut Back on PSA Testing
Earlier this year, I reported on the U.S. Preventive Service Task Force's recommendation that routine PSA tests should be discouraged for healthy men. This was just one of several controversial recommendations made by the USPTSTF (an agency of the Department of Health and Human Services), which claimed the regular PSA tests were unnecessary, might actually cause harm, and certainly added needless burdens to the soaring cost of U.S. health care, the world's most expensive.

Shortly after the recommendation appeared, I asked Dr. Constantinople for his views. He thought the recommendation to stop regular PSA testing was "outrageous" and made these points:
  • Before the regular PSA tests were adopted, 40 percent of men with newly diagnosed prostate cancer had cancer that had metastasized into their bones. That figure is now five percent.
  • Regular PSA testing has resulted in detecting prostate cancer years earlier than before.
  • Since regular PSA tests became standard, the mortality rate for prostate cancer has dropped 40 percent. The rectal finger exam catches the cancer much later, often after it has already spread into the bones.
  • As for the argument that the test shouldn't be used for men over 70 (since most autopsies on older men show they have prostate cancer but die from something else), Dr. Constantinople cautioned that when men in their 70s or 80s are first diagnosed with prostate cancer, their disease is more likely to be the aggressive cancer that requires treatment, not "watchful waiting."
  • In the early years of using the PSA test, patients were likely over-treated about 25 percent of the time. That number is significantly less now. "We still have to work at fine-tuning the test," he said.
  • The "holy grail" in prostate cancer research is to find a way to determine which cancers are likely to be aggressive, and which are likely to grow more slowly. For now, there's no way to really know.
Dr. Constantinople defined the "bottom line" this way: most patients want to get the test and learn their results so they can then make informed decisions about their choices. Patients definitely need to know the pros and cons of all options, including the option not to undergo any treatment at all.

And in cases like mine -- with cancer cells remaining after removal of the prostate -- regular PSA tests are needed to track the progression of the cancer.

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