Does Not Testing the PSA Lead to More Advanced Prostate Cancer?

Mortality from prostate cancer has diminished by almost 40% since the introduction of the PSA test in the late 1980’s. Much of this is due to the use of the PSA blood test for screening purposes. In 2011 The US Preventive Screening Task Force strongly condemned the use of PSA screening. They felt that we were finding too many inconsequential early malignancies that would not lead to death and were being over treated. In their eyes, prostate cancer treatment with surgery and or radiation carried a high price tag with multiple long term complications and the benefit of screening was not worth the risk. Prior to the USPSTF”s 2011 recommendation against screening for prostate cancer with a PSA there were 9000 – 12,000 new cases of prostate cancer diagnosed per month. In the month following the USPSTF recommendation not to screen with PSA the number of new cases dropped by almost 1400 a month or over 12%. Over the next year the decline in prostate cancer diagnosis was 37.9 % for low-risk prostate cancer, 28.1% for intermediate risk, 23.1 5 for high risk and 1.1% for non-localized cancer. Clearly if you do not look for a disease you will not find it.

In the December issue of the Journal of Urology, Daniel Barocas, MD, of Vanderbilt University and colleagues discussed the PSA testing controversy. They too noted that the consequences of not screening for intermediate and high risk prostate cancer by performing the PSA test may lead to individuals presenting with far more advanced disease that is more difficult to treat, has more complications and ultimately leads to disease related deaths. His position was debated by two major urologists in the editorial section of the journal with no firm conclusion being reached.

In an unrelated article, the Center for Medicare Services or CMS announced that it is considering penalizing physicians who test the PSA for screening in Medicare patients beginning in 2018 as part of their paying for value and quality. They said that physicians need to present their patients with an ABN (advanced beneficiary notice) stating that Medicare will not pay for this test, before the blood is drawn or face fines and penalties.

Men in their forties and older have been put in an uncomfortable and inappropriate position by health policy leaders. The truth is we are currently unsure how and when to test for prostate cancer in men with a normal digital rectal exam (DRE). The consequences of not paying for screening will not be known or understood for easily ten to fifteen years. It is clear that early stage disease has the option to be observed for progression with minimal consequences in the short term. Not enough time has elapsed for anyone to know the long term effects of this policy change. Unfortunately, men in this age group are all guinea pigs in the public health policy laboratory while the data to reach a firm scientific conclusion is assembled. The predominant policy today is spending less and doing less. With this in mind, it is best for men to see their doctor, have an annual digital rectal exam, discuss their family history of prostate disease and reach an individual decision on PSA screening appropriate for their unique situation rather than one based on large population policy.

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New Test for Colon Cancer Screening Approved

Colon Cancer RibbonThe Cologuard test is the first DNA based screening test for colorectal cancer that has received approval for use from the FDA and preliminary approval by Medicare to cover the cost of the test. The test detects hemoglobin ( a component of red blood cells) and abnormal DNA in cells picked up by stool . A positive test indicates a need for colonoscopy to identify or eliminate colon cancer as a possibility. We currently screen patients with the fecal occult blood slide test and the more sophisticated fecal immunochemical test or FIT. The new Cologuard detected 92% of colon cancers and 42% of advanced adenomatous colon polyps as compared with 74% and 24 % for FIT. While the Cologuard test was accurate in picking up more colon cancers than the FIT it had slightly more false positive tests than the traditional Fecal Occult Blood Slide.

The Center for Medicare Services ( CMS) is proposing allowing coverage of the DNA test once every three years for beneficiaries who are 50 – 85 years old, asymptomatic and have average risk of colorectal cancer. The new test adds another non-invasive means of screening for colon cancer. We will need to see the cost of the test to the individual patient and accumulate more data on its accuracy in the near future before it becomes a mainstay of colon cancer screening.

At the same time that Cologuard was approved, researchers at the University of Michigan in Ann Arbor published in the online journal Cancer Prevention Research, information showing that evaluation of the pattern of bacteria in the colon of patients improved performance and detection of colon cancer by more than 50% as compared to the Fecal Occult Blood Test alone. Researchers using DNA sequencing and polymerase chain reaction methods were able to identify distinctly different patterns of bacteria in colon cancer and pre-cancerous polyps than in patients with no colon lesions.

It is clear that as researchers apply DNA technology to cancer screening their ability to detect abnormalities and avoid invasive colorectal screening will improve. At the moment recommendations for screening colonoscopy at age 50 remain but as science moves forward that too may soon change.

Low Dose Aspirin Cuts Colon Cancer Risk in Women

AspirinNancy Cook, SCD of Brigham and Women’s Hospital in Boston and colleagues reported in the July 16, 2013 issue of the Annals of Internal Medicine that data from the Women’s Health Initiative including 39,876 women 45 years or older, who were randomly assigned to take 100 mg of aspirin every other day for ten years, experienced a 20% reduction in the risk of colorectal cancer. The study did not show that there was an all-cause reduction in mortality .

The very conservative US Preventive Services Task Force currently recommends aspirin in Women 55 – 79 only if potential benefits are greater than harms. The aspirin group did have more bleeding from peptic ulcers and gastrointestinal bleeding. The article was accompanied by an editorial comment by Peter Rothwell, MD, PhD of the University of Oxford. He felt that the risk of bleeding and the fact that there was no all-cause mortality reduction, or risk in all cause cancer reduction, should result in a tempering of suggestions for widespread use of aspirin in healthy middle-aged women. MedPage Today, the online Journal of the University Of Pennsylvania School Of Medicine, ran a comment from Dr. Randal Burt, MD, a gastroenterologist at the Huntsman Cancer Institute who felt that this was one more piece of evidence that aspirin can reduce colorectal cancer.

It is clear that there are multiple studies showing that aspirin can reduce the risk of colorectal cancer. There are studies showing it reduces the risk of a stroke in women as well.

Like all decisions to take or prescribe a medication, the risks and benefits must be examined first. It is clear to me that in a woman with a strong family history of colorectal cancer, and little or no history of gastrointestinal or systemic bleeding, an aspirin with close monitoring should seriously be considered.

Women and Cardiovascular Disease – There is A Difference Between Men and Women

Front view of woman holding seedlingThe American Society of Preventive Cardiology presented an educational seminar recently in Boca Raton, Florida to educate physicians, nurses and health care providers that cardiovascular disease in women can be very different than in men.  Failure to recognize these differences has resulted in women being under diagnosed, under treated and suffering worse outcomes.

The difference is first noticeable in pregnancy when the development of elevated blood pressure, super elevation of lipids and the development of gestational diabetes predispose young mothers to earlier, more serious, cardiovascular risk later in life. The faculty noted that women of child bearing age tend to use their obstetrician as their primary care doctor.  They suggested that women with pregnancy related diabetes, hypertension and lipid abnormalities should be referred to a medical doctor knowledgeable in preventive cardiology, post-delivery, for ongoing care.

For reasons that are unclear, women are less likely to be treated to recommended guidelines for lipids, diabetes and hypertension.  Diabetic women have a far worse prognosis with regard to cardiovascular disease as compared to men. They are less likely to be treated with aspirin, which while not as effective in preventing MI in women, is apparently protective against stroke.

Women about to have a heart attack have different symptoms the weeks, to months, before the event. They are more likely to have sleep disturbances, unexplained fatigue, weakness and shortness of breath than the standard exertional angina seen in men.   When they do have a heart attack they are as likely to have shortness of breath and upper abdominal fullness and heartburn as they are to have chest pain. They are more likely to have neck and back pain with nausea than men are.  

Since women have different symptoms than men they are more likely to be sent home from the emergency room without treatment.  They are less likely to have bypass surgery than men, less likely to be treated with the anticoagulants and antiplatelet medications that men are treated with and, they are less likely to be taken to the catheterization lab for diagnosis and intervention as compared to men.

The faculty was comprised of world-class researchers, clinicians and educators who happened to be outstanding speakers as well, bringing a vital message to our community.  They pointed out the different questions and diagnostic tests we should be considering in evaluating a woman as opposed to a man.

This was my first educational seminar through the American College of Preventive Cardiology and I thank them for the message they delivered to the medical and nursing community at probably one of the finest seminars I have had the privilege to attend.

Hope for HIV Prevention and Treatment

HIV is a disease that has evolved during our lifetime. As a clinician, during my years of training I saw men and women present to the Jackson Memorial Hospital emergency room with a strange overwhelming lung infection and a shutdown of the body’s immune response to infection. Even with aggressive treatment they failed and succumbed to the disease quickly. We had no idea what the process was back in the early 1970’s and were privileged to be around to see pioneers like Margaret Fischl, MD at the University of Miami Miller School of Medicine, begin to take on this dreaded disease in a population no one else would care for.

Hard work and millions of dollars in expense for research coupled with courageous patients has led to announcements like the one released by Michael Martin , MD of the Center for Disease Control that a drug called tenofovir, administered to high risk intravenous narcotic users, significantly reduced the risk of catching the disease. One pill a day In the 2400 volunteers, from 17 drug treatment centers in Thailand, taking one dose of tenofovir per day reduced the risk by almost half. The results were so striking amongst IV drug users that the author recommended beginning a once a day tenofovir program as a pre-exposure prophylaxis in all the high risk groups. He defined the high risk groups as men who have sex with men, heterosexual individuals and heterosexual couples where one person is HIV positive and the other HIV negative.  The drug was surprisingly well tolerated with only 8% of the patients experiencing episodes of nausea.

The purpose of discussing this article is to fan the hope among all individuals, providers and citizens, who have seen the ravages of this disease and did not believe a treatment, prevention or cure would occur in our lifetime. The presence of newer medications for prevention should not allow any of us to let our guard down and eliminate using the tried and true methods that prevent transmission of the disease.  Practicing safe sex by using condoms, avoiding sharing needles when injecting medication and being aware that when you are sexually active you are exposing yourself to your partner’s entire sexual past history will still need to be the cornerstone of prevention.

 

No CPR Policy at California Independent Living Facility

Young Man Doing Chest Compressions on Elderly ManLast month, an 87 year old resident of a California senior living facility dropped to the floor suddenly with no spontaneous respirations or heart beats. A nurse on duty immediately called 911 to summon medical assistance. The 911 operator instructed the nurse to begin cardiopulmonary resuscitation. The nurse refused stating that the facility had a policy of calling for help but not providing any medical help. The 911 operator begged the nurse to begin CPR or at least call another resident or worker to begin the CPR policy. She refused per institutional policy. When the paramedics arrived a few minutes later, the 87 year old was clinically dead.

The facility took the position that its residents or their health care surrogates knew of the “NO CPR” policy in advance and were comfortable with it. The family of the woman said they were aware of the no CPR policy in advance and were comfortable with the care and compassion the patient had received while a resident. The incident caused a national furor and outcry over the “NO CPR” policy.

In the State of Florida, those residents requesting a NO CPR or Do Not Resuscitate status need to fill out and display the yellow Do Not Resuscitate form # 1896. It is a two-part form. The larger part should be displayed prominently in one’s home, usually on the refrigerator. The smaller copy should be placed in one’s wallet and be available at all times. Your doctor will be required to sign both forms. Your physician should be given a copy for their records as well.

When you enter a hospital electively or emergently you will need to inform the staff that you have a State of Florida DNR form #1896 and they will make a copy and place it on your medical record chart. You may rescind this order and request full resuscitation status if you so desire at any time!

 

It is important before you enter or contract with a senior facility to live there that you learn what their policy is for providing all types of care. You will need to agree with the policy or you should choose to live elsewhere.

ACE Inhibitors Linked to Hallucinations In The Elderly

????????????????John Doane, MD, and Barry Stults, MD, from the University of Utah Health Science Center in Salt Lake City reported in the Journal of Clinical Hypertension on four cases of visual hallucinations in elderly patients taking the drug lisinopril for blood pressure control. ACE inhibitors are a popular and relatively safe drug. They are used for blood pressure control especially in diabetics.

The patients’ adverse effect profile has been limited to a dry allergic cough, elevated potassium, rash, angioedema and renal insufficiency.   They ranged in age from 92-101 and were being treated for hypertension or heart failure. Two had mild cognitive impairment, one had Alzheimer’s disease and one had vascular dementia. The time from beginning the drugs until hallucinations appeared varied from two months to six years. In each case when the drug was stopped the hallucinations resolved. In one case the patient was re-challenged with lisinopril and the hallucinations returned.

The authors conducted a thorough literature search and found several other reports of ACE inhibitor related hallucinations. In each case the hallucinations resolved when the drug was discontinued. It is believed that ACE inhibitors raise the level of opioid peptides causing these hallucinations. While the side effect is rare, it is certainly worth knowing about as the population ages and clinicians are looking for safe drugs to treat high blood pressure and heart failure.