New Approaches to Early Prostate Cancer

Men today diagnosed with early prostate cancer, Gleason Stage 7 or less, have the option of a new arm of care called watchful waiting. With periodic PSA blood tests, prostate biopsies and imaging studies; urologists and oncologists can follow the patient with disease felt to be not aggressive rather than radiate the lesion or surgically remove it as was done in the past. In some cases, they can watch it even closer with an approach called Active Surveillance. This week a new research treatment was made public.

MedPage Today published work by Steve Raman, M.D., of the UCLA Medical Center on his TULSA-PRO ablation clinical trial. One hundred-fifteen men with localized and low, or intermediate, risk prostate cancer underwent ultrasound blasting of the cancer using the MRI imaging equipment to direct the therapy. In his study, prostate volume decreased from 39 cubic centimeters before treatment down to 3.8 cubic centimeters after a year. Clinically significant cancer was eliminated in 80% of the study participants and 65% had no evidence of cancer after biopsy at one year. PSA blood levels decreased by 95%. The side effects were minimal with low rates of incontinence and impotence and few bowel complications.

The study leader noted that if prostate cancer reoccurred then the modalities of repeat ultrasound treatment, surgery or radiation were still possible. In August 2019, the FDA approved the TULSA-PRO Device for use. The procedure involves placing a rod-shaped device into the urethra. The device has ten ultrasound probes which are controlled by a computer program while the patient is observed in an MRI machine. The probes shoot out sound waves that heat and destroy the tissue the sound is directed at. The procedure is an outpatient procedure which can also be used to shrink a non-cancerous enlarged prostate from benign prostatic hypertrophy.

Sunscreen Ingredients are Absorbed says FDA

For years public health officials, dermatologists and primary care physicians have been encouraging people to apply sunscreen before going out into the outdoors to reduce the risk of sunburn and skin cancers.  We are taught to apply it in advance of exposure by about 30 minutes and to reapply it every few hours especially if we are sweating and swimming.   Living in South Florida, sun exposure is a constant problem so we tend to wear long sleeve clothing with tight woven fabrics to reduce sun exposure.  My 15-month old grandson, visiting last weekend was smeared with sunscreen by his well-meaning parents before we went out to the children’s playground nearby.

These precautions seemed reasonable and sensible until an article appeared in JAMA Dermatology recently.  An article authored by M. Mata, PhD. evaluated the absorption of the chemical constituents of sunscreen after applying it as directed four times per day.  The article was accompanied by a supporting editorial from Robert M. Cliff M.D., a former commissioner in the FDA and now with Duke University School of Medicine and K. Shanika, M.D., PhD.

The study applied sunscreen four times a day to 24 subjects. Blood levels were drawn to assess absorption of the sunscreen products avobenzene, oxybenzone and octocrylene.  The results of the blood testing showed that the levels of these chemicals far exceeded the recommended dosages by multiples. The problem is that no one has evaluated these chemicals to see if at those doses it is safe or toxic causing illness?

The editorial accompanying the findings encourages the public to keep using sunscreen but cautions that the FDA and researchers must quickly find out if exposure to these levels is safe for us?  We do know that the chemical oxybenzone causes permanent bleaching and damage to coral reefs in the ocean from small amounts deposited by swimmers coated with sunscreen. The state of Hawaii has actually banned sunscreens containing oxybenzone to protect their coral reefs.

The fact that these chemicals have been approved and are strongly absorbed with no idea of the consequences is solely the result of elected officials wanting “small government” and reducing funding to the oversight organizations responsible for making sure what we use is not toxic.  It is a classic example of greed and profit over public safety.  The research on the safety of these chemicals must be funded and addressed soon. The American Academy of Pediatrics and Dermatology need to advise parents of youngsters whose minds and bodies are in the development and growth stages what is best to do for their children – sooner rather than later.

American College of Physicians Breast Cancer Screening Guidance

The American College of Physicians released four guidance statements on detection of breast cancer in women with average risk and no symptoms of breast cancer.

1. Doctors should discuss with their patients the pros and cons of screening with mammography for breast cancer in asymptomatic women with a modest risk of disease between ages 40- 49 years. The potential risks of screening are felt to outweigh the benefits.
2. Clinicians should screen average risk women aged 50-74 years for breast cancer with mammography every other year.
3. Clinicians should discontinue breast cancer screening in women aged 75 years or greater with an average risk of breast cancer and a life expectancy of 10 years or less.
4. Clinical breast examinations SHOULD NOT be used to screen for breast cancer of average risk women of all ages.

These guidance statements DO NOT APPLY to women with a higher risk of breast cancers including those with abnormal screening results in the past, a personal history of breast cancer or a mutation in the BRCA1 or BRCA2 gene.

At the same meeting, data was presented discussing the problems with supplemental whole breast ultrasound in women with dense breasts.  The concern is that all this testing leads to invasive biopsies, over diagnosis and treatment of breast cancer in 1 in 5 patients and complications and increased cost to patients and insurers.  Like most recommendations on breast cancer, and prostate cancer in men, the results and conclusions from following these guidelines will not be apparent until 10 to 15 years from now.

Today’s adult women will either benefit from these suggestions, which have even included no longer teaching adult women how to perform breast self-exam, or they will be the unsuspecting research victims of cost containment. I question the competence of physicians in examining problematic breast disease if they are not being trained how to evaluate a breast and following that with clinical exams. In surgery we usually do not feel a clinician is competent and fully aware of the pitfalls of a procedure until the surgeon has done 200 or more. We additionally know that doing the procedure frequently results in better results than performing a procedure infrequently.

How will that apply if young physicians no longer examine breasts routinely?  How many, and how often, will they need to do an adequate exam to be able to perform when there is a real issue?  Do we actually wish to create a narrow panel of breast experts only at Centers of Excellence who actually know how to examine a breast and use the available imaging modalities safely and effectively?  It seems these ACP recommendations move in that direction.

For several years now I have been a supporter and champion of our community’s Women’s’ Center associated with Boca Raton Regional Hospital. Run by astute future thinking clinicians and researchers, and stocked with state of the art imaging equipment, it provides an option to meet with a counselor, assess your breast cancer risk and enter a screening pathway most individually suited to your personalized needs.  I will continue to support that choice.

Cannabis & Cannabinoids in the Treatment of Chronic Non-Cancer Pain

My 90 year old patient with spinal stenosis, diffuse osteoarthritis and now polycythemia vera was in for an office visit. He had been to see his hematologist and had been phlebotomized removing a unit of blood to control his overproducing bone marrow. He mentioned that the hematologist had sent him to a medical marijuana clinic run by a pain physician colleague of his.

The patient proudly showed me his marijuana registration license. “It doesn’t work you know. In fact I feel poorly after I take some. I have tried the oils and some edibles but it really doesn’t affect my pain in a positive way.”

Many of my patients now are licensed to receive medical marijuana for chronic pain. It’s a big business here in the state of Florida where senior citizens with chronic aches and pains are always looking for that magical pill to restore their vitality and youthfulness. His experience is unfortunately supported in the medical literature. In the May 25, 2018 issue of Pain magazine which looked at the pain relief of patients with rheumatoid arthritis, fibromyalgia, neuropathic pain and 48 other non-cancer pain conditions. The study was a literature review looking at the 104 studies published on this subject.

The findings were sobering and disappointing. They found that cannabinoids had no appreciable positive impact on pain relief. In addition it didn’t help sleep, there was no positive impression of change and there was no significant impact upon physical or emotional functioning.

I am not an anti-marijuana crusader. I see its positive impact in treating glaucoma. I see the studies citing it is more effective to deliver by smoking it than eating it or taking it in pill form.

The review studies included all forms of administration of cannabis. I just want to make sure that when authorities legalize a substance for use in pain control it is effective and not just profitable snake oil for a strong lobby of well-healed and crafty businesspeople.

Cigar and Pipe Smoking Significantly Increases Mortality Risk

My male patients express to me on a regular basis their desire to continue to smoke a few cigars per day. They are quick to point out that they do not inhale the smoke like cigarette smokers do. They also point out that their use of cigars is far fewer in number than cigarettes. They all discount the risks of the smoke, its byproducts, carbon monoxide, etc.

The Journal of the American Medical Association (JAMA) has just published a research project which looked at that subject. They followed cigar and pipe smokers from 1985 until 2011 looking at the mortality rate and the cancers they sustained. Of the 357,420 participants in the study, 51,150 died. The death rate of cigar and pipe smokers was much higher than nonsmokers and those who never smoked. There was also a much higher likelihood they would sustain a tobacco related cancer such as lung, throat, esophagus, oral cavity and bladder cancer which would eventually kill them.

It was clear the risks were higher for cigarette smokers than pipe and cigar smokers. As a physician, I will continue to encourage smoking cessation of all tobacco products.

Tobacco smoking ruins your health and kills people. Let there be no confusion about that fact.

Breath Test For Gastric Cancer

Hossam Haick, PhD, of the department of Chemical Engineering and Russell Berrie Nanotechnology Institute, Technion- Israel Institute of Technology in Haifa, Israel announced that they have developed a breath test for the detection of stomach cancer and precancerous lesions. The announcement was noted in Medpage Today, an online journal, and published in the Journal “Gut.” “Volatile organic compound marker detection based nonarray technology allows gastric cancer to be detected with high accuracy in a Caucasian population. The technology allows high-risk precancerous lesions to be detected via exhaled breath “even with the confounding factors of patient smoking, Heliobacter Pylori infection and alcohol use. It is extremely difficult to diagnose gastric cancer before an individual is symptomatic. Except for Japan and South Korea, almost no health care systems screen for the presence of gastric cancer in their population. These countries traditionally have very high rates of gastric cancer so they screen for it routinely in adults using upper endoscopy and imaging techniques.

“The future of cancer prevention relies on timely recognition and surveillance of precancerous lesions as well as early detection of the cancer, making higher survival rates and lower healthcare costs per patient achievable,” says Dr. Haick. “Detection of precancerous lesions would allow surveillance to be performed, making early detection of the transformation to cancer possible.” The publication in “Gut” looked at precancerous lesions but the goal is to additionally use this technique to follow a diseases progress and detect potential relapses.

At the current time this test is experimental, but large scale human testing is now underway in Europe. Hopefully a commercially available product will be released in the next few years.

March Is Colon Cancer Awareness Month

Colon Cancer is still the second leading cause of death from cancer in the United States despite numerous advances in screening and early detection. It is a disease that is found more commonly in black Americans with 46.7 cases per 100,000 individuals as compared to 38.9 cases per 100,000 individuals for Caucasian Americans. Death from colorectal cancer occurs in every 21.1 cases for African Americans and only 14.6 cases for white Americans.

Even with these dismal figures the cancer death rate from this disease has decreased by 22 percent over the last decade. We attribute this to increased awareness and increased screening.

All individuals should report a change in bowel habits to their doctor immediately. Blood stained stool is a cause for an immediate call to your physician. Generally at age 40 all adults should be having a digital rectal examination as part of a checkup. Stool occult blood slides or stool fecal immunoglobulin slides are used to screen for microscopic gastrointestinal tract bleeding. These tests involve placing a small smear of stool on a slide and submitting it to the lab where it is tested for microscopic blood loss. Usually a CBC or complete blood count is performed as well since gastrointestinal blood loss in small constant amounts usually produces a low blood count or anemia of the iron deficient variety.

Screening colonoscopies are recommended for all non-Black Americans at age 50. Due to the increased risk of colon cancer in Black Americans we recommend that they start screening colonoscopies at age 45. If you have a first degree relative who had colon cancer or precancerous polyps we ask that you start your screening at an age that is 10 years earlier than your relatives disease became apparent.

For those individuals unwilling to have a screening colonoscopy we can offer a CT Virtual Colonoscopy. The preparation is simpler than for a colonoscopy but the radiation dosage involved is equivalent to receiving ten years’ worth of chest x-rays all at once. If the virtual colonoscopy shows a polyp or a mass you will then need to undergo a traditional colonoscopy for biopsy and removal preceded by a traditional pre- colonoscopy bowel cleansing prep.

Cologuard is a new and attractive stool test that detects abnormal DNA associated with premalignant polyps and cancerous tumors. It is fairly new but readily available.

Numerous lifestyle choices can influence your development of colon cancer. Tobacco use is associated with an increased risk, as is drinking more than moderate alcohol. Red meat intake is associated with an increased risk of colon cancer with a 20% increase per 100 gram increase in red meat per day. Regular exercise and intake of high fiber food helps to decrease your risk of developing colon cancer.

March is colon cancer awareness month. Speak to your physician about your risk of developing this serious disease and ways to prevent it from developing. You can use the visit to establish your own personalized colon cancer screening surveillance schedule.