David Spellberg, MD, FACS Naples Urology Associates

Not only is there no perfect screening test available at this time, screening itself may be harmful to your health.

Google  76,800,000 results

What is the Prostate?  A chestnut-sized gland that produces fluid for semen  Located just below the bladder, in front of the rectum, and wraps around the urethra, the tube that carries urine from the bladder to the tip of the penis

Benign Prostatic Hyperplasia  Effects all men  Non medical treatment  Non invasive treatment  Less invasive treatment  Surgical Treatment

24,000 will die from prostate cancer in 2012

 Researchers don’t know exactly what causes this damage, but have identified some risk factors:  Age  Race  Environment  Diet  Genetics and family history

Should Men Get PSA Tests to Screen for Prostate Cancer? Wall Street Journal Report: Big Issues in Health Care 9/17/2012

NO

Prostate Cancer Task Force  Based on this work, the Task Force concludes that many men are harmed as a result of prostate cancer screening and few, if any, benefit.  A better test and better treatment options are needed. Until these are available, the USPSTF has recommended against screening for prostate cancer.  The members of the USPSTF face the same concerns and fears about health challenges as other people. This decision was reached only after extensive consideration and thoughtful debate. It is based on science and rooted in the knowledge that while everyone wants to help prevent deaths from prostate cancer, current methods of PSA screening and treatment of screen-detected cancer are not the answer.  The mission of the USPSTF is to improve the health of all Americans by sharing with them evidence-based recommendations, and empowering them and the clinicians who serve them to make informed decisions.

University of Arizona RICHARD ABLIN: 'There's no PSA level that definitely indicates that prostate cancer is present.’

Expected Harm of Screening  Most prostate cancers found by PSA screening are slow growing, not life threatening, and will not cause a man any harm during his lifetime. However, there is currently no way to determine which cancers are likely to threaten a man’s health and which will not. As a result, almost all men with PSA-detected prostate cancer opt to receive treatment. In addition to the frequent complications of biopsy that lead to a cancer diagnosis, there can be serious harms from treatment of screen-detected prostate cancer.  For every 1,000 men who are screened with the PSA test: 300 to 400 men will develop erectile dysfunction or urinary incontinence due to treatment 12 men will experience a serious cardiovascular event, such as a heart attack, due to treatment 10 men will develop a serious blood clot in his leg or lungs due to treatment  For every 3,000 men who are screened with the PSA test: 1-2 men will die due to complications from surgical treatment

Expected Harm of Screening  False-positive results. About of every 1,000 men screened receive a false- positive test. Most positive tests result in biopsy, and can cause worry and anxiety. Up to one-third of men undergoing biopsy will experience fever, infection, bleeding, urinary problems, and pain that they consider a moderate or major problem. One percent will be hospitalized for these complications.

The Bottom Line  We need better ways to screen for and treat prostate cancer. Until we make these discoveries, and even once we do, men and their families will turn to trusted health care professionals to help them make informed health care decisions. The USPSTF encourages all clinicians to have open conversations with their patients who have questions about prostate cancer and PSA testing.

PSA & Prostate Cancer  Screening will not be covered  Least expensive treatment will be covered, not necessarily the best  Further penalties or taxes for obesity, smoking, ETOH and unhealthy vices  Government control and a single payer system when Obamacare is no longer affordable

Cut Healthcare cost options  Lower reimbursements to physicians & hospitals  Lower utilization by cutting benefits  Improve the health

Four important components  PSA  Free %  PCA-3  Rectal exam of prostate

 A substance produced by prostate cells 1  The PSA test measures the amount of PSA in the blood  Very little PSA escapes from a healthy prostate  Some prostate conditions can cause a large amount of PSA to leak into the blood What is PSA (prostate-specific antigen)?

Free % PSA  Bound and Unbound  More specific  Very Useful when Total PSA is between and previous negative biopsy  Ideally % greater than 15, though the higher the better

PCA-3 Urine test  Prostate exam required prior to obtaining urine specimen  The greater amount of prostate cells found in the specimen the greater the risk of cancer

ALWAYS OBTAIN A SECOND OPINION OR A THIRD OR FOURTH

 A test that may be necessary if the results of the PSA or DRE tests suggest prostate cancer  A needle is used to remove a small amount of tissue from the prostate  Typically, multiple samples are taken  Only a biopsy can definitely confirm prostate cancer  It is still possible to have cancer even if the biopsy is negative What is a biopsy?

Study: MRI-Guided Biopsy Increases Prostate Cancer Detection. In continuing coverage, MedPage Today (12/12, Bankhead) reports, "Targeted prostate biopsy with magnetic resonance imaging (MRI) tripled the cancer yield compared with conventional systematic biopsies," according to a study published online Dec. 10 in the Journal of Urology. Leonard S. Marks, MD at the University of California Los Angeles, and colleagues, found that MRI-targeted lesions "contained biopsy-proven prostate cancer 21% of the time, whereas systematic biopsy detected cancer just 7% of the time." The study was based on "findings from a follow-up investigation involving 171 consecutive patients who underwent outpatient MR-ultrasound fusion biopsy." Dr. Marks said the technique, "which fuses MRI images with ultrasound, could revolutionize prostate cancer detection and supplant ultrasound-guided biopsies, which have been the standard of care for 25 years."MedPage Todaystudy

TREATMENT OPTIONS  WATCHFUL WAITING  SURGERY  RADIATION THERAPY  CRYOTHERAPY  HIFU  PROTON  HORMONAL MANIPULATION  CHEMOTHERAPY  EXPERIMENTAL

Naples Urology Associates mission statement is to provide concierge Urological services without additional cost.

Warren Buffett completes prostate cancer treatment

Increased treatment vs. active surveillance Purchasing of older, inferior quality machines Decreased use of new technology

PROSTATE MOVEMENT  0.2mm -7.3mm Nov 2001 Radiotherapy & Oncology, volume 61 issue 2, Wu et al.  30 seconds over 2mm Sept 2008 Intl J Rad Oncol Bio, 72(1),

Why movement is important?  Radiation cystitis and proctitis are serious complications  Local hyperbaric chamber director has commented about the lack of cyberknife patients seen but a dramatic rise in prostate cancer patients treated with rapid arc

 Patient lies comfortably on the couch while the CyberKnife robot moves, images and treats.  Treatments typically last 1 hour  Most patients require no sedation allowing them to depart at the completion of their treatment CyberKnife Treatment Delivery

New Clinical Study Demonstrates Reduced Prostate Radiation Side Effects with Calypso

1/11/2012  New Prostate Cancer Gene Mutation Discovered

REQUIRED INFORMATION  STAGE ( T1, T2, T3, T4)  GLEASON SCORE ( 2- 10)  VOLUME OF DISEASE

ALWAYS OBTAIN A SECOND OPINION OR A THIRD OR FOURTH

Obamacare.com Facts  Healthcare exchanges -State or Federal online marketplaces starting 1/2014  Medicaid and Medicare reform -17 million uninsured added to system  1.1 trillion cost over next 10 years, reducing deficit by 143 billion  99% of families & 97% small businesses will benefit  Paid for by taxes 2.5% requirement, others

143 Billion Savings  53 billion from social security payroll taxes  70 billion from premiums of a new government run long term care program  40% tax on “cadillac” health plans  3.8% medicare tax on investment income  2.5% tax on failure to purchase insurance  2.9% excise tax on medical devices  10% indoor tanning tax

Obamacare Reality  Over 90% still not written  ACO’s are the new HMO’s  More physicians will be concierge or quit, meaning longer waits  2 or 3 tiered systems

Obamacare in Reality  “we have been forced to purchase it, fined if we don’t, no new doctors have been added to treat 17 million more patients, 16,000 IRS agents are being hired to monitor the cheaters, the committee chairman who helped pass it doesn’t understand it, passed by a congress that didn’t read it but exempted themselves from it, and signed by a president who smokes cigarettes”  Dr Barbara Billar

What is the future?

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