What You Need to Know About Prostate Cancer

It's MoVember or No-Shave November and I've shaved off my beard to grow it back during this month to raise awareness -- and cash -- for men's health issues.

Seems like a good time to give the Red Triage treatment to some of these health issues.

So here goes our first What You Need 2 Know (WUN2K?)

How Do You Say It? It is pronounced ProsTATE not prosTRATE. To be prostrate is to lay flat on the ground face first in front of someone either because you are being arrested or really, really into religion. ProsTATE is a greek word meaning protector or guardian. Which allows for this fun sentence: "The prostate, prostrated himself before his King."

Why Do We Need It? The prostate is a gland that produces a liquid that protects the sperm from the acidic environment of the vagina.
This -- and the fact that prostate exams are conducted with a doctor's finger in the rectum -- make it hard to talk about the prostate at dinner parties.

Why It Causes Problems: This is a gland that wraps around the urethra just below the bladder. So if it swells up for any reason, it makes urinating difficult. It's not really in the penis, but messing around with it through surgery can affect a man's ability to have sex and urinate. These are two things men really like to do.

Can We Live Without It? Sure, it is one of the glands a guy could get along without. It would be harder to make babies, but not have sex. The problem comes in getting rid of it. It is located in a spot where a lot of the blood vessels and nerves running to the penis are also located. As noted above, collateral damage is possible and can lead to problems having sex and urinating.

What is Prostate Cancer? Think of cancer as runaway evolution starting with one cell that has an error in its programming. It reproduces like crazy and makes more bad copies. These cells can sometimes spread to distant parts of the body. Different cells make different kinds of cancer and those cancers cause different kinds of problems and symptoms. They act differently. Some causes big problems, pain and death. Some cause minimal problems and there are probably cancerous growths that are never discovered and are handled by our bodies defenses.

Nowhere is this more evident than in prostate cancer. There are different types - a slow growing kind and more aggressive, fast growing kinds. It has been said that most of us men - if we live long enough -- will probably die WITH prostate cancer, but not FROM prostate cancer. That's because the slow growing kind of prostate cancer is much more common. This kind does not spread to other parts of the body or mutate like the more aggressive types.

 Lies, Damn Lies and Statistics:
Prostate cancer is the most common cancer in men.
It is the second leading cause of cancer death for men in the United States.
An estimate 238,590 men will be diagnosed this year.
Approximately 29,720 will die from it.

Survival rates are good with 98 percent surviving 10 years after diagnosis and 93 percent surviving 15 years after diagnosis. However, while death from prostate cancer is declining among all men, it is still twice as high for black men than white men.  (source, American Cancer Society via Cancer.net ) Black men have a high incidence of prostate cancer and tend to get the more aggressive form. 

Testing, Testing: This is an area where there has recently been controversy. A test for Prostate Specific Antigen has been around for years, but the test is not as specific to prostate cancer. Cancer cells in the prostate spit out large amounts of this protein, but PSA is also found in higher-than-normal levels in men other various prostate conditions, such as benign prostatic hyperplasia (BPH, an enlarged prostate) and prostatitis (inflammation or infection of the prostate). Because it is an easy test to add on to routine blood work, many men may have had this test and not even know it. 

So, if the PSA level is high, it may indicate that a man has an aggressive prostate cancer that has yet to become symptomatic.

Or it might not.

Here's what the American Society of Clinical Oncology has to say:

 In some situations, PSA testing finds aggressive prostate cancers early and save lives. However, it is not easy for a doctor to predict which tumors will grow and spread quickly and which ones will grow slowly. In some situations, men who have a prostate cancer that will never cause them harm may be discovered, and this discovery means these men will undergo additional testing and treatments that turn out to be unnecessary. These tests and treatments put a man at risk for infection, impotence, incontinence, and rarely, death. Each man’s risk of prostate cancer and acceptance of potential side effects is different.

So if you are over 50, you should talk with your doctor about whether PSA testing is appropriate and if the test comes back positive, what the plan will be. New guidelines allow doctors to take a "watch and wait" approach, rather than initiate invasive testing. (For more on this, see earlier post on Medical Testing.)

How Do I Not Get This:
Don't get old (80 percent of all prostate cancer is diagnosed after age 65) and eat a low fat diet with lots of fruits and veggies. Will that prevent prostate cancer? We don't know but it can't hurt and some research seems to point in that direction.

Don't go crazy with supplements like Selenium and Vitamin E. The SELECT study looked into these and found that they not only did not prevent prostate cancer, but may have caused more harm than good.

This seems to be a type of cancer that doesn't rely on genetic inheritance, although if you have close family members (son, brother, father) that were diagnosed at a young age, your chances are higher of developing the disease.

The Jury's Still Out: One area of research is a link between vasectomies and prostate cancer. One study in 1983 showed an increased risk, however subsequent review has shown that the link between the two is very small and the increase in risk if they are linked, is also very small. Size does matter. Get the vasectomy.

Poor Tools Available For Fighting Seasonal Flu

Image Credit: Tamiflu

Influenza this year has reached epidemic proportions - now widespread in almost all 50 states and overwhelming hospital resources on the East Coast. 

Over at National Geographic, Carl Zimmer points out that, while the flu comes back and kills half a million people a year, it is pretty incompetent as far as epidemics go - unfortunately, our tools to respond are worse.

The fact that this year’s seasonal flu has overwhelmed us (shutting down some hospitals, in fact) doesn’t bode well for the inevitable moment some time in the future when we do come face to face with a much meaner flu strain.

The trouble lies not just in our creaky hospital system, but in the weapons we have on hand. There’s a flu vaccine, thank goodness, but it’s only about62% effective. Making matters worse, well under half of Americans get vaccinated each year. If you get sick, doctors don’t have a lot of options for treatments. 

Indeed, the other night I asked a provider if she wanted a flu swab. "Why," she said. "It doesn't change how we are going to treat it."

There are of course antiviral drugs on the market. Tamiflu being the most available drug. It is given out quite readily to anyone who demands it from their doctor and is even being used as prophylaxis after influenza exposure. 

How effective is Tamiflu? The joke around the hospital is that if you get the flu, it will be gone in two weeks. IF you take Tamiflu, it will be gone in 14 days. Actually, one study found that the duration of the disease symptoms is reduced on average of 20 hours. Moreover, in most otherwise healthy patient populations, using the drug caused little reduction in hospitalization or complications when compared with placebo in several studies.

So what's the harm? Well, there are side effects and adverse events that have been reported. Just about every drug -- including placebo if you coach for it -- has listed side effects of nausea, vomiting and abdominal pain. However, it is not often that you see this warning on a label:

Neuropsychiatric events: Patients with influenza, including those receiving
TAMIFLU, particularly pediatric patients, may be at an increased risk of
confusion or abnormal behavior early in their illness. Monitor for signs of
abnormal behavior. (5.2)

What kinds of confusion or abnormal behavior? Japanese cases involving abnormal behavior including a handful of deaths in pediatric patients lead regulators there to institute restrictions on prescribing the drug to those between the ages of 10 and 19 starting in 2007. 

Neurological and psychological disorders were listed as possible side effects including impaired consciousness, abnormal behavior and hallucinations. Convulsions,  seizure like activity and neurological symptoms such  delirium, hallucinations, confusion, abnormal behavior, convulsions, and encephalitis. have been reported as well, but infrequently given the widespread use of the drug.

So do we have underreporting of adverse events due to all the other factors involved in a patient suffering from a viral illness, or are these neurological side effects just so rare that it is hard to establish a causal relationship.

Still, a busy flu season has renewed the hype and demand for the only drug out there indicated for seasonal flu. Moreover, the company that makes it still refuses to release full data from the trials - which is suspicious.

Further reading: (See: The Myth of Tamiflu: Five Things You Should Know ) and the British Medical Journal's Open Data Campaign.