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PSA and Prostate Cancer

Does PSA screening reduce death due to prostate cancer?

PSA-based screening for prostate cancer remains a controversial issue, says an article in the Canadian Medical Association Journal (CMAJ).

Some health authorities in the United States advocate prostate cancer screening in men who ask about the PSA test. On the other hand, the Canadian Urological Association and most health authorities in the European Union still discourage the practice of prostate cancer screening, says Dr. Andre N. Vis, author of the CMAJ article.

In the United States, there was a gradual increase in the death rate from prostate cancer over several decades. But since 1993, the death rate from prostate cancer has gradually declined by 17.6 percent. Same thing has happened in Canada. Between 1991 and 1996, the death rate has declined by 10 percent.

Here is another example. Quebec experienced a 47 percent increase in the incidence rate of prostate cancer between 1989 and 1993. Probably due to introduction of PSA test. And the rate of prostate cancer death rate in Quebec decreased by 15 percent between 1995 and 1999.

The question is – is this decline in the death rate due to the effectiveness of screening with the PSA test? The PSA test was introduced in North American medical practice by the end of 1980s.

Some experts believe that the decline in the death rate from prostate cancer is due to better treatment options, change in diet and lifestyle, and may be improvement in environmental conditions. Not due to PSA screening.

Linda Perron and associates who did the research on the effectiveness of PSA screening in Quebec, says that, “In accordance with the observational studies described here, our results do not support the hypothesis that the present decline in prostate cancer mortality is attributable PSA screening.”

Perhaps the jury is still out on the effectiveness of screening for prostate cancer by PSA test. That does not mean that we should ignore our prostate. Thirty percent of men over 50 will have prostate cancer, but only 10 percent of these men will be diagnosed and treated for prostate cancer and three percent will die of the disease.
That means we have to be vigilant. We have to use whatever methods we have to detect prostate cancer early and treat it. And the methods of early detection available to us are two: digital rectal examination (DRE), and PSA blood test.

If you don’t have any symptoms of prostatic cancer does not mean you don’t have prostate cancer. That is why there is a big drive to screen asymptomatic men over 50 with DRE and PSA blood test.

Although DRE has a cancer detection rate of only 0.8 to 7.2 percent, it remains an important test that can be done easily in a doctor’s office. It also checks for anal and rectal tumours.

PSA blood test has a false positive rate of 20 to 50 percent and false negative rate of 25 to 45 percent. That means 30 to 50 percent of the time the test is wrong! So why do these tests if the returns are this low? The reason is simple – this is the best shot we have to get an early diagnosis!

If you are 50 years or older, and if you want to have your prostate checked out – in fact you should get it checked out – then talk to your doctor about digital rectal examination (remember, if you don’t let your doctor put a finger in your rectum to check your prostate then he might end up putting his foot into it!) and PSA blood test.

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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How To Loose Weight

How much should Canadians eat?

That’s the question I ask of myself when I look at my girth in the mirror. Or stare at my bathroom scale six feet away from my eyes.

The other day, I took my last dress pants to a seamstress to make room for my ever-increasing girth. She says, “Dr. B, do some exercise!”

I thought I did enough exercise each week. May be I am eating too much! I did not think so. I thought I did both – ate less and did regular exercise. So what am I doing wrong? Why am I not losing weight?

I am not the only one asking this question. Million of Canadians and others in the world are asking the same question. What are we doing wrong?

Dr. C. Laird Birmingham, Professor of Medicine, University of British Columbia and Dr. Peter J. Jones, Professor of Dietetics and Nutrition, McGill University, have published an article in the recent Canadian Medical Association Journal (CMAJ) titled: How much should Canadians eat?

The professors believe that the current methods for assessing energy intake are flawed. These methods underestimate actual energy intake. Does that mean we are eating more than we think? The article also reviews new methods for measuring the energy content of foods and address the problem of energy expenditure in obese people.

Obesity is defined as an excessive accumulation of body fat. The body mass index (BMI) of over 30 is considered to be obese. BMI is measured by dividing the weight in kilograms by the square of the height in meters. Currently, about 20 to 30 percent of North American adults have BMI of 30 or more. These people roughly have 50 to 100 percent higher mortality rate than those with BMI of below about 25.

How do people become obese? When the amount of energy absorbed exceeds expenditure – the net gain of energy ends up as body fat. The authors say that the current wave of obesity epidemic are due to shifting perceptions about what constitutes a “normal” portion size, the increased availability to pre-prepared foods and the more sedentary “couch potato” lifestyles of individuals within developed societies.

The Canada Food Guide provides guidelines for food intake in Canada. Nutritionists follow these guidelines to advice individuals who want to lose weight. “Unfortunately,” says the CMAJ article, “the existing values contained in these guidelines are out of date.” They provide estimates of energy requirement that are erroneously low.

There are also biases in the methods used to measure expenditure of energy. Until these methods (for energy intake and expenditure) have been revised and updated, the energy intake should be individualized based on observation of outcomes based on BMI, blood lipids, and waist measurement, says the CMAJ article.

The most reliable indicator of energy balance or imbalance is individual’s weight. If a person is not losing weight then he is eating more than what he needs and he is not exercising enough – income is more than expenditure!

Whatever methods we use for measuring energy intake and output, one problem will always be there – obese people always underestimate their energy intake.

So, how much should Canadians eat? Is there an ultimate diet plan? Yes, listen to your weighing scale and measure your waist, if it ain’t going down then you are eating too much! And the best exercise you and I can do is to push ourselves away from the table. That is called will power! Your girth and weighing scale will tell you how much you should eat.

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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Irritable Bowel Syndrome

Are your guts driving you nuts?

Then the problem may be in your head. Not in your guts.

What’s your head got to do with your guts?

Well, we are talking about stress. Stress can play havoc with your body. Stomach and intestine are very sensitive to stress. And the result is – irritable bowel syndrome (IBS).

IBS is not like other conditions. There are no definite abnormalities to find in a patient with IBS and there are no tests to confirm the diagnoses.

How do we know a person has irritable bowel syndrome?

Mainly by symptoms of abdominal pain, bloating and irregular bowel movements. And by ruling out other conditions of the gastrointestinal tract.

IBS is a complex condition that affects a person’s psychology (emotional and behavioural characteristics). A physician treating this condition must have a good understanding of the problem. He should be able to dedicate time and energy to help his IBS patients.

IBS is considered to be a functional disorder of the gastrointestinal tract. But there is high incidence of psychiatric disorders in patients with IBS – panic disorder, major depressive disorders, and phobias.

Patients have to realise that they may need psychological treatment for a physical condition. And having irritable bowel does not mean a person is mentally ill. Antidepressants and medications that inhibit anxiety have been shown to be effective in IBS. But these drugs have to be used with care.

Stress-induced anxiety can make symptoms of IBS worse. The source of stress can be internal (from within your own body) or external (from your environment). IBS patients experience higher levels of anxiety and fatigue than do healthy people.

In more severe, treatment-resistant IBS, psychotherapy has been proven to be useful. But there is no evidence to suggest that psychotherapy is beneficial in patients with mild IBS. Before psychotherapy is instituted, a physician should rule out some of the common conditions of the gastrointestinal tract – ulcers, inflammation (inflammatory bowel disease), and cancer.

Management of IBS poses a big challenge to a physician. Many drugs are available in the market for use in IBS. But none of them have proven benefits. Some of them may act as placebo. Smooth muscle relaxants tend to help relieve abdominal pain with or without relief of other symptoms of IBS. Loperamide (Imodium) is beneficial in patients who have diarrhoea as a predominant symptom.

Current treatment of IBS includes advice on high fibre low fat diet, smooth muscle relaxant, agents to stop diarrhoea or bloating and psychotherapy or psychoactive drugs to take care of depression or anxiety.

If your mind is playing games with your guts then stop and ask, “Who is playing games with my mind?” If it is your own thought process then take control of it – try exercise, laughter and meditation. If it is your environment, then get out of that environment. Create your own environment of happiness and relaxation. It can be done, if you have the desire and willingness to accept change.

Remember, if you take care of ELMOS (exercise, laughter, meditation, organic healthy food, stress management) then ELMOS will take care of you and your IBS!

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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Skiing and Stress Relief

Let’s talk about skiing and stress relief.

In last Friday’s Talk of the Town column, Angus Henderson wrote about Hidden Valley Ski Resort. I am glad he did that. I am very fond of that place.

I like to commend Kevin Fischer and his staff. They do a wonderful job of running the place. Kevin is a very approachable fellow. Always has a smile on his face. His staff is always very cheerful, friendly and helpful.

Kevin’s presence is always visible and his hands-on leadership is very evident.

My family and I love Hidden Valley. I started taking ski lessons eight years ago when my son joined the Nancy Green program. He has been a fast learner. He now snowboards.

My daughter also likes to ski but my wife felt that she would be a good family cheerleader than a skier! And supply us with hot chocolate, lunch and snack during breaks! Not a bad deal!

For me the progress has been slow. I have fear of heights and speed. And as a surgeon, I did not want to break my wrist and be out of commission for several months. But I was determined to learn and be with my family.

I was born and brought up in Tanzania. I had never seen snow in Africa except in pictures. Mount Kilimanjaro in Tanzania is famous for snow-capped peak. But I never got a chance to get there. In any case, there is no skiing on Mount Kilimanjaro.

Over the last eight years, I have made slow but sure progress. Many young instructors and friends at Hidden Valley, Sunshine and Canada Olympic Park helped me get through my fears. Now I can ski all the hills at Hidden Valley except Suicide and Showoff. This year my target was to be comfortable on the Hidden Valley run. I successfully did it several times. Next year, the plan is to get over the fear of Suicide run! Showoff, probably never!

Each year, by October, I am looking forward to winter, snow and skiing. I find skiing very relaxing and good for stress relief. A good example is what happened last week. It was a busy week and in some respects a very traumatic week at work. It culminated in a very exhausting and draining Friday meetings.

I am glad I had a weekend off to recover. For two days, my son and I went skiing at Hidden Valley. The weather was great. Snow was excellent. The weekend of skiing completely refreshed me.

At Hidden Valley, you are amongst happy people. Unlike golfers, skiers are always smiling and are ecstatic when they come flying down the hills. Skiers don’t shout “fore” and you don’t hear anybody swear!

Skiers are not rushing or pushing you to keep moving. They don’t phone the clubhouse because of “slow play”. There is no marshal in a red power cart chasing you around the ski hills. Instead, you see helpful ski patrols and instructors.

At Hidden Valley, beginners and experienced skiers have fun together. Good skiers don’t look down on beginners or show any signs of arrogance. In fact, they are willing to share their experience. It’s like a big happy family.

Do you know what happens to a golfer after he dies? Saint Peter sends him straight to heaven because he has suffered enough on the golf course!

For skiers, heaven is at Hidden Valley and other ski resorts. Skiers don’t have to worry about life after death. It is heavenly all the way!

Now, am I putting my golf club membership in jeopardy? Glen Carr, don’t worry. I will be there when the golf course opens. In summer, golf course cannot be worse than health care politics!

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