Had Your Butt Checked Out Lately?

There are more jokes and humorous videos on the internet about colonoscopy than about mammography or cervical cancer screening. The reason is quite obvious. Most people do not like the idea of people inserting long tubes and cameras in the rear end of our anatomy. That is where the problem lies. Out of fear and embarrassment, we ignore that area and by the time we pick up cancer it is too late.

Alberta Cancer Board, Canadian Cancer Society and Alberta Health Services have been very aggressive in promoting the Alberta Colorectal Cancer Screening Program. You must have read about it in the newspapers, heard about it on the radio and seen the news on TV. The question is: what have you done about it? Are you ready for it?

The program aims to save lives by improving the prevention and early detection of colorectal cancer in Albertans between the ages of 50 and 74. The sad part is only 10 to 20 per cent of Canadians come forward to have some kind of screening test done for their colon. More women would go for mammography and cervical cancer screening than colorectal screening. And men are worse when it comes to screening for colorectal and prostate cancer.

Men and women are almost equally at risk of getting colorectal cancer. There is a less than three minutes video on YouTube (http://www.youtube.com/realmenscreen) titled: “Had your butt checked out lately? – The Canadian Cancer Society asked men this question.” It is humorous and educational. Check it out!

Colorectal cancer is the fourth most common cancer. The average lifetime risk of developing colorectal cancer is six per cent. It is the second leading cause of cancer death in Canada. It is expected that colorectal cancer screening will decrease both, incidence and mortality.

Most people are scared as soon as they hear the word colonoscopy. It is important to remember that colonoscopy is not the only test for screening although it is the best test and is considered as gold standard against which other screening tests are compared. In certain circumstances (high risk patients) you do not have a choice but go through a colonoscopy for diagnosis, prevention and treatment of certain conditions.

You are at a high risk of getting colorectal cancer if you have a family history of colorectal cancer or polyps, have a personal history of ulcerative colitis or Crohn’s colitis
and have had polyps or previous history of colorectal cancer.

If you have symptoms like rectal bleeding then you don’t have a choice – you need a test. Depending on your age, the test may be a flexible sigmoidoscopy in the office or colonoscopy at the hospital. For example, six per cent of the patients who say they are bleeding from hemorrhoids have colon or rectal cancer.

Every individual is at risk of developing colorectal cancer. If you have no symptoms, have no family history of colorectal cancer and you are 50 years or older then you do not have to go through colonoscopy. You have a choice of doing stool tests for occult blood yearly or bi-annually, flexible sigmoidoscopy in an office every five years or combine stool test and flexible sigmoidoscopy every five years.

Every test for screening has advantages and disadvantages. None of them are full proof. And they vary from very invasive (colonoscopy) to least invasive (stool test). If you fall into high risk category then colonoscopy is the way to go. If you are asymptomatic person with an average risk then you have a choice of tests mentioned earlier.

So don’t be scared, talk to your doctor and have your butt checked out!

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For Men Prostate Problems are Almost Inevitable

A gentleman said, “Doc, how come you have not written about prostate problems lately?” He was right. Sometimes I feel I have written about a subject recently but when I look back at my list on the computer, I find time does go by fast. So, here is some information about prostate problems.

On a personal note, I am proud to say that this is my 400th column. I appreciate all the feed back and encouragement I receive from readers from all walks of life. Not only I enjoy writing but I learn a lot myself when I do all the research for my articles. I have learnt to take care of my health better thanks to these columns.

Ok, let us get back to our subject.

“Prostatic disease eventually affects almost all men; benign prostatic hypertrophy or hyperplasia (BPH) is an inevitable part of aging,” says an article in the Canadian Medical Association Journal (CMAJ June 19, 2007).

Do we need to worry about prostatic hypertrophy or hyperplasia which in simple terms means prostatic enlargement? Sure, we have to worry. Who knows, it could be malignant. Although prostatic enlargement eventually affects almost all aging men, not all men suffer from prostatic cancer. The lifetime risk of diagnosis of prostatic cancer is 18 per cent and death from prostatic cancer is three per cent.

Enlarged prostate gland has several effects. These include difficulty with voiding urine and blood PSA levels may go up. Other complications are urinary retention, urinary bleeding, bladder stones, recurrent urinary tract infections and renal failure. These effects become progressively worse requiring frequent medical attention and rising PSA requires multiple tests to rule out prostate cancer.

About 20 years ago, the standard treatment for benign enlargement of prostate gland was surgery. Now, patients with mild symptoms do not need any treatment. Patients with moderate symptoms are treated with medications. These medications have shown to improve the flow of urine and improve the quality of life. Do these medications prevent complications of BPH? Studies have shown that this is possible.

The two major classes of drugs used to treat BPH are: a) alpha-blockers like doxazosin relax smooth muscle fibers of the bladder neck and prostate gland to reduce prostatic obstruction, b) five- – reductase inhibitors like finasteride decrease levels of testosterone in the prostatic gland itself but do not affect the systemic testosterone level. This leads to reduction of the prostate gland by 20-30 per cent.

With -blockers, patients experience relief of symptom within two weeks of starting the medication, compared with several months with finasteride. Researchers have found that doxazosin and finasteride slowed down the growth of BPH compared with placebo; the combination therapy was significantly more effective than either drug alone.

The CMAJ article says that the Medical Therapy of Prostatic Symptoms study showed that:
-BPH is a progressive disease
-progression can be prevented by medical therapy
-patients at risk for progression can be readily identified by PSA level, prostatic volume and symptom severity
-and the combination of finasteride and doxazosin is more effective than either alone in preventing progression, particularly in high-risk groups.

Are there any side-effects to these medications?

The article says that clinically significant side effects, mainly postural hypotension (low blood pressure), were infrequent and they led to cessation of therapy in 18–27 per cent of the men involved in the study. Side effects that occurred were minor and related mainly to sexual function.

Patients treated with finasteride had significant benefit with improvement in urinary symptoms. There was also an added advantage in that the finasteride-treated patients saw reduction in the overall risk of prostate cancer by 25 per cent – a rate almost unheard of in the field of cancer prevention, says the CMAJ article. The authors of the article say, “Because PSA levels are reduced in men with BPH who are taking finasteride, rising PSA findings are more likely to be caused by prostate cancer. Taking this drug may therefore provide a diagnostic advantage as well.”

The article poses the question: Should selected patients now be offered finasteride to lower their risk of developing prostate cancer and BPH progression?

“The answer, based on these trials, is unequivocally yes,” conclude the authors of the CMAJ article.

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Controversial Role of PSA in Early Detection of Prostate Cancer

Controversy regarding the use of PSA (prostate-specific-antigen) in early detections of prostate cancer continues with the recent publication of an article in the New England Journal of Medicine (NEJM).

Prostate cancer is the most frequent cancer and the second leading cause of death from cancer in men, exceeded only by lung cancer. In 2008, an estimated 24,700 men were diagnosed with prostate cancer and 4,300 died of the disease.

The walnut size prostate gland lies below the urinary bladder in front of the lowest inch of the rectum, through which it can readily be felt on digital rectal examination (DRE). The gland has an important role in the proper flow of urine. It also provides the proteins and ions that form the bulk of the semen. In conjunction with other smaller glands in the vicinity, the prostate gland produces secretions that serve to lubricate the reproductive system and provide a vehicle for storage and passage of sperms.

Once upon a time, “the old finger” i.e. DRE was the only crude way to pick up early prostate cancer. 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.

The PSA test was introduced in North American medical practice by the end of 1980s. PSA was expected to replace the embarrassing and uncomfortable DRE. And it was promoted as an ideal test for screening and early detection of prostate cancer. But this hope has not materialized. 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.

The editorial in the NEJM says, “In the United States, most men over the age of 50 years have had a prostate-specific–antigen (PSA) test, despite the absence of evidence from large, randomized trials of a net benefit. Moreover, about 95 per cent of male urologists and 78 per cent of primary care physicians who are 50 years of age or older report that they have had a PSA test themselves, a finding that suggests they are practicing what they preach.”

Recent clinical trials have shown that PSA screening without DRE was associated with a 20 per cent relative reduction in the death rate from prostate cancer at a median follow-up of 9 years, with an absolute reduction of about 7 prostate cancer deaths per 10,000 men screened. Critics say that this is at best a modest effect on prostate cancer mortality and the benefit comes at the cost of substantial over-diagnosis and over-treatment. There is net harm compared with potential benefits.

Experts agree that PSA testing is an imperfect screening tool. They say the test is as effective as programs such as mammography for breast cancer and fecal occult blood testing for colorectal cancer.

The Canadian Cancer Society recommends that men aged 50 and older discuss the benefits and risks of PSA testing with their physician, and the society does not plan to change its recommendation based on recent research.

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