Category: Medicine Hat News

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Is PSA test a public health disaster?

Sand art on the beach in Albufeira, Algarve, Portugal. (Dr. Noorali Bharwani)
Sand art on the beach in Albufeira, Algarve, Portugal. (Dr. Noorali Bharwani)

Dr. Richard J. Ablin, PhD, DSc (Hon), first discovered prostate-specific antigen (PSA) in 1970. At the time, Ablin and colleagues were trying to identify an antigen that was specific to prostate cancer.

PSA test was introduced in the United States around 1990 for early detection of prostate cancer.

In 2010, Ablin called the PSA test a public health disaster. So, what went wrong? Why do we still order PSA test?

Let us start from the begining.

All men have a prostate gland. The gland produces some of the ingredients of semen. It sits just in front of the rectum and below the bladder. It can be felt on a rectal examination. It weighs about 30 grams. It is vital for the proper functioning of the male reproductive system.

One of the enzymes in prostatic fluid is prostate-specific antigen (PSA). After ejaculation, PSA makes thickened semen runnier, helping sperm travel through it more easily. Thus, increasing their likelihood of successfully fertilizing an egg.

Why PSA test can do more harm than good?

Reviewing some literature, I found Ablin, who is now a research professor of immunobiology and pathology at the University of Arizona College of Medicine and the president of the Robert Benjamin Ablin Foundation for Cancer Research, has said, “in approving the procedure (PSA test), the Food and Drug Administration relied heavily on a study that showed testing could detect 3.8 per cent of prostate cancers, which was a better rate than the standard method, a digital rectal exam.” Was that a wise decision?

PSA test is costing health care system billions of dollars. It is estimated that each year, some 30 million men undergo PSA testing in the US, at a cost of $30 billion. Ablin has said the test is hardly more effective than a coin toss. The PSA test cannot distinguish between the two types of prostate cancer – the one that will kill you and the one that won’t.

The American Cancer Society now urges more caution in using the test and the American College of Preventive Medicine has concluded that there was insufficient evidence to recommend routine screening. Then why do we still use it?

“Many doctors have distorted perceptions of the value of medical tests,” says Dr. Miriam Shuchman in the Canadian Medical Association Journal (CMAJ February 04, 2019). And patients have the same distorted perceptions.

In 2014, the Canadian Task Force on Preventive Health Care recommended against using the PSA test to screen for prostate cancer in healthy men, concluding that it results in substantial harms via biopsies and surgeries that can lead to infections, impotence or urinary incontinence, and does not save men’s lives.

Canadian and American task forces recommend that any man considering screening for prostate cancer should have a chance to first discuss the pros and cons with a doctor. The CMAJ article says that if men knew what the risks were associated with PSA testing and how slim to nonexistent the benefits are, no man in his right mind would get tested.

Considering PSA screening results in only a 0.1 per cent reduction in death from prostate cancer, the harms associated with screening outweigh the benefits for most people.

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Sun safety and prevention of skin cancer starts in childhood.

Dubai Desert Safari. (Dr. Noorali Bharwani)
Dubai Desert Safari. (Dr. Noorali Bharwani)

Snow has melted and summer is around the corner. It is about time to get some sun exposure and vitamin D. But we have to be careful. We have to find a right balance. Too much sun exposure allows ultraviolet (UV) rays to reach your inner skin layers that gives you sunburn. Sunburn kills your skin cells and cause cancer. You don’t want that.

UV rays are invisible, and are produced by the sun and tanning lamps. Most often, skin cancer is the result of overexposure to sun. Good news is most cases of skin cancer can be prevented.

There are three types of skin cancers. Basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma. The first two are common and have good prognosis but can disfigure your face. Melanoma can be lethal if not treated early. Melanoma is the least common, but most serious type of skin cancer.

Who gets melanoma?

The rate of melanoma has tripled in the last 50 years. Melanoma is the deadliest skin cancer. It accounts for only about one per cent of all cases of skin cancer, but is responsible for the vast majority of skin cancer deaths.

In men, melanoma is most commonly found on the back and other places on the trunk (from the shoulders to the hips) or the head and neck. The most common sites in women are the arms and the legs. People with fair skin, such as those with Scandinavian ancestry, are more prone to sun damage than people with darker skin.

Approximately two per cent of melanomas occur in patients under the age of 20 years, and about 0.4 per cent of melanomas occur in prepubertal children. Children spend more time outdoors than adults. It is known that high exposure to sunlight during childhood sets the scene for higher rates of melanomas as an adult. Your risk of skin cancer increases with level of total cumulative exposure to the sun and number of sunburns. Melanoma loves overexposed and burnt skin.

What happens after diagnosis?

Your doctor will investigate if the melanoma is at an early stage or advanced stage. Early-stage means the cancer hasn’t grown much and hasn’t spread. Treatment is more likely to be successful.

Advanced-stage melanoma usually means the cancer is bigger and has probably spread. It’s important to know the stage of a cancer. It helps decide on your treatment.

Most early melanomas can be treated with wide surgical excision. But prognosis drops dramatically when the tumor has spread. There is no curative treatment available for advanced melanoma.

While we are waiting for scientific breakthrough in many areas of melanoma, we can try and prevent melanoma by protecting against sun exposure and sun burn. Natural protection (shade) is considered the best protection. And sunscreen (SPF 15 or higher) should be adjunct to natural protection.

Wear sun protective clothing (tightly woven). Wear wide brim hats. And use eyeglasses that block both UVA and UVB light.

Skin is the largest organ in the body. It is a very precious and important organ. It has many important functions. It is important for our survival. Let us protect it well starting from childhood. There is no doubt melanoma risk rises rapidly with increasing exposure to ultraviolet light in childhood. That is where the prevention should start and then continued into adult life.

Have a wonderful safe summer.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Aging gracefully after retirement is a challenge we all face.

Space Needle in Seattle. (Dr. Noorali Bharwani)
Space Needle in Seattle. (Dr. Noorali Bharwani)

Today, people are living longer than they did 60 years ago. Now we have extra 15 to 20 years. Barring any unfortunate incidence most people will live to 80 years. Women will live longer.

The question is: how to grow older in good health so that we can actually enjoy those extra years? A Consumer Reports survey of 2,066 Americans age 50 and older revealed that we are eager to maintain our quality of life into retirement and far, far beyond.

As we get older our health changes. This happens even if we don’t like it. These changes can be due to normal aging process or age-related diseases. Most of our activities in life depend on our health and how mobile we are. Our retirement goals, such as travel, choice of home, sports and a broad range of other activities depend on our health.

Financial independence is also very important. Have you saved enough to get the help you need in case you are dependent on others?

What kind of health issues we should be worried about in our retirement?

Here is a list of health issues you have to be prepared for as you get older:

Are you capable of driving? If your vision is not good and you have difficulty with concentration then you cannot drive. Make sure you see your eye doctor on a regular basis.

How mobile are you? Arthritis, stroke, feet problems, and other health issues affecting your mobility will create frustration and anger. Joint deterioration can compromise your ability to stay active or climb stairs. Some of these problems come with the aging process. Be active and keep your muscles strong to mitigate the effects of these problems.

Are you able to hear your friends and family talk? Are you able to enjoy listening to music and watch television? Hearing loss can interfere with your relationships and lead to isolation. Don’t be shy to wear a hearing aid. Be proactive. Do not wait till you are completely hard of hearing.

Do you have cognitive deterioration? That means you have difficulty thinking and making decisions that affect your everyday life. This is feared by all. Alzheimer’s in old age makes it difficult to interact socially. You become dependent on others. Maintaining an active social network for yourself and being a lifelong learner are the best ways to reduce the risk of cognitive decline.

How can we take a proactive approach to prepare ourselves to make a smooth life transition?

Unfortunately, there is no magic solutions to the problems mentioned earlier. The basic principles are to prepare for what is to come. Be proactive and prepare yourself when you are young and healthy. Understand the importance of exercise, healthy diet and good health habits like no smoking.

If you are living in a big house then think about downsizing. Do it early when you are still in good health and in sound mind. Do not depend on your family to do it when you have lost control of your life. If you want to have choice, control and independence throughout your life, you need to think about these things early.

Not able to drive can cause severe frustration and anxiety. You should plan carefully where to live. Your social life will rely on whether you can get around. People do not realise how so many elements of their retirement plans are dependent on transportation. The problem gets worse if your friends are of the same age and cannot drive.

It all comes down to keeping control of your life and anticipating and planning for lifestyle changes as we age.

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Osteoporosis and prevention of fractures in the elderly.

A walk on the beach in Maui. (Dr. Noorali Bharwani)
A walk on the beach in Maui. (Dr. Noorali Bharwani)

Recently, I came across a good article on osteoporosis and prevention of fractures in the elderly written by Dr. Erika Dempsey, clinical assistant professor with the University of Calgary (MD Scope, March 7, 2019).

Osteoporosis is a condition in which there is loss of calcium and a gradual softening of the bones that make them fragile.

Osteoporosis leads to an increased incidence of fractures resulting from low impact injury. Sometimes no injury is involved in case of spontaneous fractures of vertebrae. Believe it or not, 80 per cent of all fractures in patients over the age of 50 are thought to be related to osteoporosis. Osteoporosis affects more women than men because of hormonal (estrogen) changes at menopause. This causes bone loss and softening.

There are several reasons why we should control osteoporosis. Osteoporosis is exceedingly costly, both for the patient and the health care system. Osteoporosis Canada estimates that acute care for patients with hip fractures alone will cost Alberta over $62 million in 2020. 

This does not include increased costs of care after discharge. Roughly a quarter of the patients with hip fractures will require institutional care on a long-term basis. A person with hip and spinal fracture may die from medical and/or surgical complications. One-year post-operative death for hip fracture patients is 25 to 30 per cent.

Should individuals over 50 be on vitamin D and calcium supplements?

Both calcium and physical activity are important to build and maintain strong bones. Ingesting the recommended daily amounts of calcium primarily through dietary sources and staying physically active appear to be the best approaches to limit your fracture risk.

Sometimes we forget how regular exercise builds strong bones.

We need vitamin D to absorb calcium. Vitamin D enhances absorption of calcium.

Vitamin D is necessary for building and maintaining healthy bones. That’s because calcium, the primary component of bone, can only be absorbed by your body when vitamin D is present. Your body makes vitamin D when direct sunlight converts a chemical in your skin into an active form of the vitamin.

Vitamin D isn’t found in many foods, but you can get it from fortified milk, fortified cereal, and fatty fish such as salmon, mackerel and sardines.

Dr. Dempsey suggests treatment of osteoporosis should be accompanied by vitamin D supplementation (800-2000 IU daily) and 1200 mg/day of (preferably dietary) calcium. Do not start these pills without consulting your family doctor.

If the osteoporosis begins before menopause then estrogen loss alone cannot account for the changes. Other causes of osteoporosis for men and women are: long-term use of cortisone, smoking, heavy drinking, sedentary lifestyle, low body weight and medical conditions that affect absorption, such as celiac disease. Diagnosis of osteoporosis is made by measuring bone mineral density.

The current national guidelines recommend the test for osteoporosis (measuring bone mineral density) should be done every two to three years.

How to prevent hip fractures?

All individuals over the age of 50 should consult their doctors and seek advice. General recommendations are: get enough calcium and vitamin D, do regular exercise to strengthen bones and improve balance. Do weight-bearing exercises, and do walking that helps you maintain peak bone density for more years. Avoid smoking or excessive drinking.

Walking has other advantages. “All truly great thoughts are conceived while walking,” says Friedrich Nietzsche. Let us walk and change the world!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!