Prostate Cancer

“Is it my prostate, doc?” Dave asks me at the golf course as he rushes to the washroom for the fifth time.

As a travelling salesman, Dave finds it difficult to make many washrooms stops. He makes an appointment to see me.

Dave is 40. His father has had prostate cancer. Dave wants to know what are his risks and what can he do for prevention and early detection.

The prostate is a small gland, usually weighing about 20 grams. It surrounds the urethra where it joins the bladder. Enlargement of the gland causes voiding problems and may cause bleeding in the urine which may or may not be visible.

Prostate cancer is, after lung cancer, the most common cause of cancer-related death in men. The risk of developing prostate cancer increases with age. At 40, the probability of prostate cancer occurring within five years is 0.01 per cent. At 80, it is eight per cent.

Although the risk is only eight percent, it is important to note that 80 per cent of men at 80 will have prostate cancer. But this will not affect life or life expectancy.

“What’s up doc?” Dave greets me as I enter the examination room.

We discuss symptoms. In a physical examination we find his prostate is slightly enlarged, smooth but quite firm.

There are no hard lumps to cause alarm at this stage.

Although most prostate cancers are diagnosed at 70, they can occur at a younger age. Since Dave has a family history and his prostate is enlarged and firm, he is referred to Urologist for further investigation.

Dave has a blood test – prostate-specific antigen (PSA). This is slightly abnormal. Therefore he has rectal ultrasound and a needle biopsy. This is reported as normal.

“Doc, how often should I have checkups for my prostate?” Dave asks.

His Urologist indicates Dave should have a repeat antigen test in three to six months.

If this is abnormal then he may need a repeat prostate biopsy.

Screening is recommended for men 50 and over. Half the men in this age group develop prostate problems. This may or may not be due to cancer.

Digital rectal examination and antigen tests are recommended for screening high risk patients like Dave. Although neither tests are hundred percent accurate for early diagnoses, they are accepted as part of routine medical checkups.

Dave is happy there is no cancer and his anxiety level improves. He feels reassured about his health.

He is ready to hit the road for another few days of good salesmanship.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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Breast Lump

Dave and Susan were anxiously waiting for me.

Since her last visit, Susan has practiced breast self examination. She found a breast lump.

Susan is aware that breast cancer is the most common cancer diagnosed in Alberta women. It also accounts for about 21% of all cancer deaths in women (Breast Cancer – The Picture in Alberta: 1998).

Susan came straight to the point. She told me about her breast lump.

“Dr B, do you think it is cancer?”

“Susan, I will have to do some investigations before I can answer your question.”

I started with clinical history. How long the lump has been present? Has any change been noted? Is there a previous history of breast biopsy or breast cancer?

Age is the most significant risk factor for breast cancer in women. At age thirty, the probability of developing breast cancer in the next five years is 1 in 667. At seventy, it is 1 in 65.

Susan is thirty eight. Her risk is 1 in 208.

Any other risk factors? Susan’s sister had breast cancer. It is estimated that less than 10 percent of all breast cancers have genetic predisposition.

Breast cancer may or may not be painless.

A fine needle aspiration biopsy of the lump was required to establish whether the lump is solid or cystic. A cystic lump has a very low probability of cancer. I also arranged a mammogram. This would provide further information on the nature of the lump. It would also pick up smaller lumps which were not felt during the physical examination.

Susan and Dave were made aware that eighty percent of breast lumps are benign in nature but a breast lump is suspected to be malignant unless proved otherwise.

Within a week I had good news for Susan. The needle biopsy and mammogram did not reveal cancer. She was advised to see me seven to ten days after she starts her next menstrual cycle.

Susan arrived as planned.

I gave her another physical examination to see if the lump had changed or even disappeared. The lump was still there.

Unfortunately, none of the tests we do are hundred percent accurate to rule out cancer.

“Doctor, I know this. I have been talking to my sister. What’s next for me? A surgical biopsy?”

Yes. This would entail a surgical procedure under local or general anesthetic.

Susan underwent day surgery as planned. There was no cancer.

I saw Susan again a few weeks later. She was happy and relieved.

“Doctor, what should I do to stay one step ahead of the game?”

Mammography and physical examination are the mainstay of screening in breast cancer (Cancer Screening in 1995; Current Oncology; March 1995).

Susan got ready to leave. I gave her some pamphlets to read.

“Call me if you have any questions,” I said as Susan stepped out of the door.

She smiled and said, “Thank you, doctor!”

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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

Screening Tests for Cancer Prevention

I was expecting a visit from Susan.

My imaginary friend, patient and Susan’s husband, Dave, had warned me about this a few days ago.

Susan wanted to know how screening tests can prevent cancer.

Susan had good reasons to worry about cancer. Her sister had surgery for breast cancer. Her mother has had colon cancer. Susan’s recent pap smear was abnormal.

Susan is thirty eight years old. Weighs 130lbs. She is five feet seven.

She is very athletic. Plays squash and racquetball. Jogs regularly.

Does not smoke and drinks alcohol socially.

Susan works as legal secretary and has two children.

Susan is a fine example of a healthy person. Can anything go wrong with her health?

Unfortunately, yes!

“Hello Dr B, I hope you are having a good day today!” Susan greeted me as I entered the examination room.

“Yes, Susan, I am having a wonderful day.”

I was running on time. I didn’t have to give any bad news to patients that day. Sun was shining and I was looking forward to a relaxing evening with my family.

Unlike Dave, Susan likes to call me Dr B or doctor. I have never heard her say “What’s up doc?”

Without wasting any time, Susan came straight to the point: “Doctor, what are my risks of developing cancer?”

“Cancer will develop in 1 in 3 Albertans during their lifetime” says the Alberta Cancer Board document, A Snapshot of Cancer in Alberta (1996).

“What about my family history, doctor? That does put me at a higher risk than other Albertans. Surely, I need to be more careful.”

Yes, Susan is right. Unfortunately, we are all at the mercy of our genes.

“Doctor, is there a difference how cancer affects men compared to females?”

Yes, men outnumber women in total numbers of cancers and deaths related to cancer.

It is also important to remember that there is a high level of premature deaths from cancer among women than men. Some of the cancers affecting women tend to occur at a younger age, says the Alberta Cancer Board document.

“Dr B, what are the top five cancers which kill Alberta women?”

Breast cancer tops the list. This is followed by lung, colon and rectum, unknown primary (original site of cancer cannot be found) and pancreas.

“What about men?”

Lung, prostate, colon and rectum, stomach and pancreas in that order.

“Doctor, what about cancer of the cervix?”

Cancer of the cervix has been decreasing among Canadian women. This is most likely due to the widespread use of pap smear, says the Cancer Board document.

“Dr B, what sort of screening tests would you recommend for me and Dave?”

Cancer screening in 1995 is an interesting article (Current Oncology -March 1995) written by Dr B. P. Higgins. He mentions five tumor sites where screening has been recommended.

“What are these sites, doctor?”

Prostate, breast, colon and rectum, ovary and cervix.

Susan looked at her watch. It was time to pick up Andrew and Tamara from school.

“Dr B, can I bring along Dave next time so we can go through this together?”

“Sure, Susan. I would be happy to sit down and discuss this with both of you.”

Susan stepped out of the examining room. After a couple of steps, she turned back and whispered,” Doctor, do know what Dave said the other day?”

“What did he say?” I asked. She smiled. I asked again, “Susan, what did he say?” Curiosity was killing me.

“He said that trying to stay healthy was more difficult than ………improving his golf game!”

I was having a wonderful day and I wasn’t going to spoil it by talking about golf. Golf…..who invented that game?

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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

Premature Death

Doc, what are my risks of dying prematurely or getting chronically disabled? How can I change this? Dave had left my office last time with these questions in mind.

Dave is six feet tall. Weighs 210lbs. Smokes twenty cigarettes a day. As a travelling salesman he entertains his clients to lunches and dinners.

His wife Susan, always worries about his life style.

Dave rarely misses his appointments. He arrived on time. My receptionist admires his punctuality.

By the time I saw him, I was running late by fifteen minutes.

“Whats up doc?” Dave greeted me in his usual style. “Not busy today? I guess you have plenty of time to give me a pep talk.”

First, we discussed the leading causes of death in Alberta. According to Alberta Health (1994), heart diseases is the number one killer (39%), followed by cancer (25%), lung diseases (8%) and other causes (28%).

Accidents, alcoholism and suicide form major portion of “other causes”.

In U. S., it is estimated that fifty three percent of deaths are premature occurring before the age of sixty five.

“Doc, is there anything we can do about this?” Dave queried.

Yes, we can. With appropriate preventive measures, significant number of these patients could live to enjoy the next century.

“Doc, these are interesting numbers. What about me? Tell me what I need to do to improve my chances of staying healthy? I guess my life style is not ideal!”

Dave looked serious. I was glad that the questions came from him. As we know, whatever the age, people in general do not always choose habits which are good for their health.

Is it easy to change habits? No, it is not easy unless there is a desire and motivation to change. Change requires discipline, determination, devotion and dedication (the four Ds).

“Doc, you sound like my golf instructor! In any case, for the sake of my family and myself, I need to change. Give me five commandments for promoting good health.”

Five commandments? Sounds cool! Here we go:

1. Dave, quite smoking. An average smoker looses fifteen years of life from lung cancer, heart disease, emphysema, stroke and other illnesses.

2. Exercise, Dave, prolongs life, reduces fractures in old age and improves function and mood.

3. Weight, for your height and age, should be maintained. A combination of nutritious diet and exercise can do that for you, Dave. Obesity is a risk factor for many illnesses.

4. Physical check ups with your family doctor are worthwhile. They remind you to stay in good health. If a condition is detected early then it can be cured or controlled.

5. Alcohol drinkers, Dave, compared to non-drinkers, have increased injury and death. Death is from cirrhosis of liver, alcoholism and cancer of various organs.

Dave was speechless. He wiped his forehead. Glanced at his watch and said: “Doc, aren’t you running late?”

Indeed, I was.

Dave got ready to leave. He looked serious. Did I upset him? Should I remind him about the four Ds?

No. He needs time to digest. I will wait for his call. He will probably need more help to follow the “five commandments”.

“Susan wants to know about the screening tests you had mentioned last time. Would you mind discussing with her?”

“Dave, it would be my pleasure,” I said as I watched him slowly shuffle his way out of my office.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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

Graduates of foreign medical schools: false hope.

Canadian Medical Association J, Vol. 132, May 15, 1985

Letter to the Editor

Graduates of foreign medical schools: false hope

I read Chouinard’s article on foreign-trained physicians with interest (Can. Med. Assoc J 1985; 132: 231).

Most graduates of foreign medical schools who come to North America have no illusions about the problems facing them. The fact that they have to take a number of “knowledge” – testing examinations and the experience of dealing with several licensing bodies in one country prepare them for the worst, unlike in the United Kingdom, where there is one licensing body for four countries.

What upsets foreign-trained physicians is the deliberate coolness or harassment of some of the licensing bodies. The physicians are kept running from pillar to post to fulfil the requirements in a frustrating vicious circle consisting of the evaluating examination, rotating internship, licensing by the Medical Council of Canada and postgraduate training for certification.

Most foreign-trained physicians suffer in silence, afraid of offending those in authority. There is no organization sympathetic to their plight, and their point of view is rarely heard.

I have experienced such obstruction twice. In 1979 I was told by the College of Physicians and Surgeons of Alberta (CPSA) that to practise as a surgeon in Alberta I had to be a licentiate of the Medical Council of Canada and a fellow of the Royal College of Physicians and Surgeons of Canada. After I had fulfilled these criteria, I was told that I should be a Canadian citizen or landed immigrant (which I am) and that the CPSA was “reluctant to register anyone who is outside the province unless they are actually going to start working in this province”. When I protested this new requirement, I was told that it had been laid down in the Medical Profession Act and its bylaws since 1975. Why did the CPSA not tell me at the start what the act required?

The second experience occurred when I was offered a fellowship in surgical oncology by the M.D. Anderson Hospital and Tumor Institute in Houston. I had been working towards this goal during my research and residency years, and when I received the offer I was ecstatic. I was eligible for a licence in Texas, but when it came to obtaining a non-immigrant visa for 1 year of training in the United States, the Education Commission for Foreign Medical Graduates refused to approve my application because I had not passed the basic science portion of the Visa Qualifying Examination. Anyone who has taken this test knows how difficult it is to pass a pure basic science examination after being qualified for 5 to 10 years. I had to have up-to-date knowledge in basic medical science to obtain a temporary visa.

Graduates of foreign medical schools are ready to take up any challenge to make themselves acceptable and useful in Canadian society once they are allowed to enter the country. The ultimate effects of obstruction on their personal and professional lives are largely unknown. It is time someone looked at this problem.

Noorali Bharwani, MB, BS, FRCS (Edin), FRCS (Glasg), FRCSC
North Battleford Medical Clinic
North Battleford, Sask.

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