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Prostate malignancy, Cancer

Darling, I Decided To Get a Second Opinion

 By Dr. Gifford Jones

“How many angels can dance on the head of a pin?” That’s a tough question to answer. Almost as hard as providing logical answers to questions of the PSA test used to detect prostate cancer. A recent report in the New England Journal of Medicine (NEJM) claims that the accepted normal PSA value of 4.1 misses 15 per cent of prostate malignancies.

To correct this problem it’s been suggested that the normal level for PSA should be lowered to 2.5. But a Texas study of 3,000 males aged 62 to 91 revealed that 6.6 percent of these males with PSA levels of only 0.5 had prostate cancer! It appears no value is totally safe.

The PSA test measures the level in the blood of a protein produced by the prostate gland. A cancerous prostate makes much more of it. But it’s long been recognized that the test is not the be-all-and-end-all in diagnosing prostate malignancy. First, three out of four men with an elevated PSA do not have cancer. Rather, the elevated PSA is due to benign enlargement of the gland, infection or inflammation.

Dr. Ballentine Carter, a Professor of Urology at Johns Hopkins School of Medicine, in Baltimore, Maryland, says, ” This study reinforces something that is very important. Prostate cancer is very, very common especially if men who have PSAs even less than 4.0 very commonly have prostate cancer”.

PSA testing presents a major dilemma. Physicians know that although they have the ability to detect many prostate cancers, they’re also aware that many of these malignancies will never cause harm.

Years ago one of the world authorities on prostate malignancy reminded us that, “growing older was invariably fatal, cancer of the prostate only sometimes.”

Epidemiologists also argue that there is no proof that PSA screening saves lives. That one in three men in their 40s have microscopic traces of cancer in their prostate gland, but only four per cent will die from the disease. In many instances getting prostate cancer is no more important than growing gray hair.

Since only a few with cancer of the prostate will die from the disease, who then do you treat? Unfortunately, no test answers that question.

Some authorities argue that doctors should take an aggressive approach when treating prostate cancer. But this would make sense if the treatment was not sometimes associated with serious complications such as impotence and urinary incontinence.

It’s my belief that urinary incontinence is under-reported. Doctors tend to forget that a patient with this problem is much more aware of the annoyance than the surgeon who performs the operation! And patients are often reluctant to report it.

Getting older has little to be said for it. But in this disease, the older one gets the easier it is to make a decision. Does a 70-year-old man want to risk ending his life in diapers or becoming impotent when even without treatment prostate cancer may take 15 years to kill him? In the meantime there’s a good likelihood that something else will end his life. It’s often better to live with the devil you know than the devil you don’t know.

This question is more difficult when prostate cancer is diagnosed at 45 years of age. Now you need the wisdom of Solomon to make the right decision between radical surgery, cryosurgery (freezing the prostate gland) and radiation, or a combination of treatments.

What is needed is a better test that can separate these gray hair cancers from the ones that will kill you. And currently this test is not available.

In the meantime, particularly before agreeing to radical surgery, remember this story. A man had a fight with his wife, accused her of a variety of sins and finally stormed out of the house, calling back “Besides, you’re a lousy lover”. A few days later, feeling guilty, he returned home and found his wife in bed with another man. She calmly explained, “Darling, I decided to get a second opinion”.

It’s equally sound advice for this disease.

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Dr. Gifford Jones  Bio
Dr. Gifford Jones Most recent columns

W. Gifford-Jones M.D is the pen name of Dr. Ken Walker graduate of The Harvard Medical School. He’s been a ship’s surgeon, hotel physician and family doctor and later trained in surgery at McGill in Montreal, University of Rochester N.Y. and Harvard. His medical column is published by 60 Canadian newspapers and several in the U.S. He is the author of seven books. Dr. Walker has a medical practice in Toronto. His Web site is: http://www.mydoctor.ca/gifford-jones



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