prostate cancer


Study: Black Men With Prostate Cancer More Likely To Get Worse Care Than White Men

A new study of men 65 or older with localized prostate cancer shows that black men may receive poorer care than white men in treatment for prostate cancer. (M. Spencer Green/AP)

A new study of men 65 or older with localized prostate cancer shows that black men may receive poorer care than white men in treatment for prostate cancer. (M. Spencer Green/AP)

Imagine you’re a 70-year-old black man with prostate cancer. Here’s what a new study reveals about your outlook:

You’re far more likely to get worse medical care than your white counterparts, including more time waiting for your surgery and more emergency room visits and hospital readmissions after surgery. You’ll also likely spend more money on your care. Oddly, though, that inferior care won’t necessarily translate into a worse chance of survival.

The study, published online by JAMA Oncology, specifically looked at a group of men on Medicare with localized prostate cancer. The standard of care for such patients involves either removal of the prostate gland (called a radical prostatectomy or RP), radiation therapy, a combination of the two, or active surveillance (close followup of patients).

Prostate cancer is one of the most frequently diagnosed cancers among men in the U.S., with estimates of about 220,800 new cases in 2015 and approximately 27,540 deaths.

Researchers analyzed data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER)-Medicare database for 26,482 men 65 or older with localized prostate cancer who underwent radical prostatectomy. The patients included 2,020 black men (7.6 percent) and 24,462 non-Hispanic white men (92.4 percent).

Some key findings:

59.4 percent of black men underwent RP within 90 days vs. 69.5 percent of white men.

Black men had a seven-day treatment delay compared with white men in the top 50 percent of patients.

Black men were less likely to undergo lymph node dissection.

Black men were more likely to have postoperative visits to the emergency department or be readmitted to the hospital compared with white men.

The top 50 percent of black patients had higher incremental annual costs for surgery, spending $1,185 more compared to white patients.

I asked the study’s lead researcher, Quoc-Dien Trinh, M.D., of Brigham and Women’s Hospital in Boston and Harvard Medical School, to further explain the findings. Here, edited, is our conversation:

Rachel Zimmerman: What are the most extreme examples of disparities you found between black men and white men treated for prostate cancer?

Quoc-Dien Trinh: Blacks were 35 percent less likely to undergo surgery with 3 months of diagnosis; Blacks were 45-48 percent more likely to require a visit to the emergency department after surgery; Blacks were 28 percent more likely to be readmitted after surgery; Blacks were 24 percent less likely to undergo a lymph node dissection at prostatectomy.

How do you account for these dramatic differences in care?

It is possible that blacks are not receiving their care at the best institutions and/or with the best providers. Continue reading

Pathologist’s View On Prostate Cancer Grey Zone: ‘What Do My Numbers Mean?’

Prostate cancer, circled. (Photo courtesy Dr. Michael Misialek)

Prostate cancer, circled. (Photo courtesy Dr. Michael Misialek)

By Dr. Michael Misialek
Guest Contributor

We don’t like to admit it but cancer is rarely black and white. Increasingly a cancer diagnosis means living in a murky morass of constantly reassessing risk.

Here’s one man’s story of living on that precarious line. His saga, seen through a pathologist’s filter, illustrates the uncertainties surrounding prostate cancer. And, as the number one cancer in men, it is increasingly becoming a familiar story for many. Questions like, ‘What do my numbers mean?’ ‘Should we treat or not?’ and if so, ‘Which treatment is best for me?’ inevitably arise.

Mr. B. is a 64-year-old man who was found to have an elevated PSA four years ago on his routine physical exam. Obviously, prostate cancer was the first thought that came to mind, particularly since his father had the disease. What he soon learned is that prostate cancer is a complex diagnosis — one that requires the careful integration of the physical exam, biopsy results, radiographic studies and lab results.

And, of course, it’s a diagnosis that comes with many decisions and choices; choices that depend upon understanding the grey zone of medicine. Prostate cancer is rarely clear cut. As much as numbers like the PSA and Gleason score (the sum of the two most predominant grades in a patient’s tumor) guide diagnosis and treatment, they also contribute to the uncertainties on the best course of action.

When Mr. B’s elevated PSA was first detected, his primary care physician referred him to a urologist at Newton-Wellesley Hospital. His prostate was normal on physical exam and they elected no biopsy at the time. Over the next couple of years the PSA slowly continued to rise, still with no change in his physical exam. Last year a biopsy was done and was negative. No cancer, a relief. What was found was some inflammation. Could this have contributed to the rise in PSA? It certainly could have, but a negative biopsy did not rule out cancer. The journey of watching numbers continued.

This year Mr. B.’s PSA rose yet again, and his urologist ordered an MRI which was negative. Mr. B. underwent another biopsy. (Not an easy process since he takes the blood thinner Coumadin and any invasive procedure needs to be carefully coordinated with stopping and restarting this medication.) The biopsy is also uncomfortable: his first biopsy involved six needles, but this time it was twelve.

The slides came to me. I put them on my microscope and carefully studied each of them. As I scanned at low magnification I found two tiny foci of abnormal glands which qualified for a diagnosis of cancer. Continue reading

Why To Exercise Today, Guys: Better Prostate Cancer Outcomes (And We May Know Why)

There are about 2,617,682 men currently living with prostate cancer in the United States, according to the National Cancer Institute. And sometimes, at this age, it seems like everywhere you look, another man is getting diagnosed, watching and waiting, or getting treated for prostate cancer.



Exercise has already been shown to lower the risk of death among prostate cancer patients, but now, researchers report that may have a clue why, and it’s to do with brisk walking.

It turns out that “men who walked at a fast pace prior to a prostate cancer diagnosis had more regularly shaped blood vessels in their prostate tumors compared with men who walked slowly,” according to new findings presented in San Diego at the American Association for Cancer Research-Prostate Cancer Foundation Conference on Advances in Prostate Cancer Research.

Here’s more from the news release:

Men who engage in higher levels of physical activity have been reported to have a lower risk of prostate cancer recurrence and mortality compared with men who participate in little or no physical activity. The biological mechanisms underlying this association are not known.

“Prior research has shown that men with prostate tumors containing more regularly shaped blood vessels have a more favorable prognosis compared with men with prostate tumors containing mostly irregularly shaped blood vessels,” said Erin Van Blarigan, Sc.D., assistant professor in the Department of Epidemiology and Biostatistics at the University of California, San Francisco. “In this study, we found that men who reported walking at a brisk pace had more regularly shaped blood vessels in their prostate tumors compared with men who reported walking at a less brisk pace.

“Our findings suggest a possible mechanism by which exercise may improve outcomes in men with prostate cancer,” continued Van Blarigan. “Although data from randomized, controlled trials are needed before we can conclude that exercise causes a change in vessel regularity or clinical outcomes in men with prostate cancer, our study supports the growing evidence of the benefits of exercise, such as brisk walking, for men with prostate cancer.” Continue reading

Regret Over Shorter Penis After Prostate Cancer Treatment, Study Finds

Patients facing treatment for prostate cancer expect to be warned of certain dismal side effects: erectile dysfunction and incontinence, for instance. But a new study suggests men should be warned of another possible complication: a shorter penis.

The new report found that a small number of men enrolled in a prostate cancer study complained to their doctors that their penises seemed shorter following treatment (though no actual measurements were taken). Some of the men reported that even this perception of a shortened penis interfered with their intimate, emotional relationships and caused them to regret the type of treatment they chose.

(Wikimedia Commons)

(Wikimedia Commons)

Prostate cancer is the second most common cancer in men, with about 241,740 new cases diagnosed last year, according to the American Cancer Society. Obviously prostate cancer can be serious: it’s the second leading cause of cancer death (behind lung cancer) in American men.

But most men diagnosed with prostate cancer will live — and live with the short- and long-term implications of the type of treatment they choose to undergo. While the problems of erectile dysfunction and incontinence are widely known as possible side effects, few studies have been done on treatment-related penile shortening. But doctors say it can and does happen — though it’s rarely discussed with patients.

In the current study, which was based on surveys completed by physicians treating 948 men with recurrent cancer, a total of 25 patients (2.63%) complained of a shorter penis. Complaints were most common in men who underwent surgery to have their prostate removed (19 of 510 men) and those treated with male hormone-blocking drugs combined with radiation therapy (6 of 225 men), researchers report. None of the men on radiation therapy alone complained of this particular problem.

These numbers are clearly small; but researchers say the phenomenon, due to its intimate nature, is likely underreported. The takeaway from this study, they say, is that the possibility of a slightly shorter penis after treatment should be made clear to patients as they consider their therapeutic options; a frank discussion upfront might minimize later regret. “Physicians should discuss the possibility of this rarely mentioned side effect with their patients to help them make more informed treatment choices,” the study, published in the medical journal Urology, concludes.

From the January issue of the journal Urology

From the January issue of the journal Urology

Lead author Paul L. Nguyen, M.D., a radiation oncologist at Dana-Farber Cancer Institute and Brigham and Women’s Cancer Center in Boston, said the novelty of the work is that it shows how even the perception of a shorter penis can profoundly impact a man’s quality of life and lead to regret. “Some people might think this is frivolous — who cares about a slightly shortened penis — but it really does affect people’s lives,” he said in an interview. “If guys [in the study] had this bad result they were much more likely to regret the path they chose. This is important to talk about up front when people are making their decisions.” Continue reading

Prostate Round-Up: The Ever-Growing Appeal Of Watchful Waiting

Invasive prostate cancer cells

I stand accused (by a man) of paying little heed to recent important prostate news because I lack that particular bit of anatomy myself.

Guilty. But please let me make up for my neglect. Here’s a round-up of the latest wisdom on prostate cancer, and here’s its bottom line: In the prostate cancer field, “watchful waiting” — officially known as “active surveillance” — has never looked better.

Dr. Philip Kantoff, director of the Lank Center for Genitourinary Oncology at Dana Farber Cancer Institute: “This study strongly supports the option of active surveillance in men with good-risk prostate cancer.”

The study he was referring to is just out in The New England Journal of Medicine here, and it’s a high-quality study that randomly assigned 731 men with localized prostate cancer either to surgery or to observation.

Dr. Philip Kantoff” (Courtesy of DFCI)

A decade later, the outcomes of the two groups were strikingly similar: In the prostate surgery group, 171 of 364 men, or 47 percent, died. In the observation group, 183 out of 367, or 49.9 percent, died. “Among men assigned to radical prostatectomy, 21 (5.8%) died from prostate cancer or treatment, as compared with 31 men (8.4%) assigned to observation,” the study reports. How can this be? Prostate cancer is often “indolent;” it can grow very slowly and pose little threat for a long time.

A bit more from Dr. Kantoff: “This is a very important study. It supports what we have known for some time, that there is a great deal of over-treatment of prostate cancer, particularly for men with low risk prostate cancer. More and more physicians and patients are adopting active surveillance as a viable option for men with low risk prostate cancer.” Continue reading

A Prostate Screening Picture Worth A Thousand Words

Prostate cancer early detection

The Max Planck Institute for Human Development has just kindly given us permission to post this excellent chart depicting the effects of prostate screening on men over 50. It goes with this post from yesterday — Analyzing those widespread feelings of ‘Hands off my PSA test‘ — and illustrates the reasoning behind recent recommendations against routine prostate screening for healthy men.

I love the feeling of dawning clarity as my eye passes slowly over the data and the point comes across: Hmmm, 1,000 men in each group. With prostate screening, the same number of men die of prostate cancer as without screening (red circles with a P inside). But with screening, a couple of hundred get “false positives” that worry them but turn out okay. And 20 are treated unnecessarily for prostate cancer, with all the downsides of the treatment, to no benefit (blue circles with an X inside). Okay, I think I get it now…

A couple of points from the folks at the Max Planck Institute: Continue reading

Harvard Med School Class of ’14 Wets Its Pants (In Video Parody)

Members of the Harvard Med School class of 2014 have a long, stressful, sleep-deprived way to go until they graduate, but at least they have a powerful sense of humor — and extremely high production values! — to help them through. According to its YouTube and Facebook text, The Jubilee Project and the Harvard Class of ’14 produced the 3-minute video above — a med-school parody of Lonely Island’s “Jizz In My Pants.” (I wonder if I could even write that title if this were a newspaper?) Sophomoric, yes, but so well done, and guaranteed to produce (disbelieving) smiles…

Hat-tip to Tinker Ready for the tweet!


Dana-Farber Expert: The ‘Wrong Message’ About Prostate Screening

Dr. Philip Kantoff

Dr. Philip Kantoff, a leading expert on prostate cancer, is not usually the outspoken public critic type. But this time is different.

The director of Dana-Farber’s Lank Center for Genitourinary Oncology, he is very publicly decrying a federal task force’s recent recommendation against routine prostate screening for healthy men. On the Dana-Farber Cancer Institute’s homepage, he puts it clearly: The panel’s report “is the wrong message.”

So what’s the right message? I asked to speak to him with a particular question in mind: Is “watchful waiting” — officially known as “active surveillance” — the central problem? That is, is the PSA screening test drawing federal fire and causing men to be over-treated for prostate cancer largely because it’s just so hard to be told you have cancer and not do something very interventionist about it? Would PSA screening be more acceptable to medical authorities if we stopped over-reacting to the results?

‘The PSA created a bunch of problems but it is a clear advance.’

But the issue is too complex to distill it down to one question. Here’s our conversation, lightly condensed. My takeaway from Dr. Kantoff’s explanations:

Turning thumbs down altogether on the PSA test would set prostate cancer treatment back 25 years. Instead, we need to refine how the test is used. Men with short life expectancies should not be screened at all; some men with elevated PSA levels should not get biopsies. And most of all, more men should opt for restrained ‘active surveillance,’ hard as it may be.

Q: On the Dana-Farber Web page, you say the latest recommendations on prostate screening are the wrong message. What’s the right message?

Let’s begin with a 3-minute overview:

The PSA [Prostate-Specific Antigen] test was developed around 20-plus years ago, and has been used widely in The United States, and it has allowed us to make the diagnosis probably 10 years earlier than before.

It therefore did two things: It pushed back the date of diagnosis — and the stage at the time of diagnosis — so that very few people presented with metastatic disease when they came in the door, as was the case prior to the advent of the PSA.

But at the same time it uncovered a lot of cancers that did not need to be diagnosed, that were non-lethal cancers. However, for quite a number of years in the United States, people treated everything that came their way.

The downsides Continue reading

Why To Exercise Today: Prostate Cancer Survival — And Survival In General

Invasive prostate cancer cells

A large new study from the Harvard School of Public Health finds that in men diagnosed with prostate cancer, those who exercised moderately — 90 minutes or more a week of vigorous walking — tended to live longer. And those who exercised vigorously — more than three hours a week — tended to clobber the cancer: they cut their risk of dying from prostate cancer by 61 percent.

This fits well into my sense that the minutes you spend exercising tend to come back to you, and then some. From the study’s release:

Boston, MA – A new study of men with prostate cancer finds that physical activity is associated with a lower risk of overall mortality and of death due to prostate cancer. The Harvard School of Public Health and University of California, San Francisco researchers also found that men who did more vigorous activity had the lowest risk of dying from the disease. It is the first study in men with prostate cancer to evaluate physical activity after diagnosis in relation to prostate cancer-specific mortality and overall mortality.

The study appears in an advance online edition of the Journal of Clinical Oncology.

“Our results suggest that men can reduce their risk of prostate cancer progression after a diagnosis of prostate cancer by adding physical activity to their daily routine,” said Stacey Kenfield, lead author of the study and a Harvard School of Public Health researcher. “This is good news for men living with prostate cancer who wonder what lifestyle practices to follow to improve cancer survival.”

The results showed that both non-vigorous and vigorous activity were beneficial for overall survival. Compared with men who walked less than 90 minutes per week at an easy pace, those who walked 90 or more minutes per week at a normal to very brisk pace had a 46% lower risk of dying from any cause.

Only vigorous activity—defined as more than three hours per week—was associated with reduced prostate cancer mortality. Men who did vigorous activity had a 61% lower risk of prostate cancer-specific death compared with men who did less than one hour per week of vigorous activity.

The Politics Of Prostate Cancer Screening

Have guidelines over prostate cancer screening been bogged down by politics?

The Wall Street Journal blog reports that a staffer for a federal task force that was scheduled to vote on the controversial issue of prostate cancer screening is quitting the panel in protest.

Family medicine physician Kenneth Lin says in a blog post that he will quit as a staff support person for the United States Preventive Services Task Force, which was supposed to meet for a vote on the risks and benefits of prostate cancer screening. Instead, the meeting was cancelled. In his post, Lin suggests the issues surrounding the task force signal that “politics trumped science.”

You will no doubt remember what happened the last time the task force issued guidelines, on mammograms for breast cancer screening? (The panel late last year recommended that only women aged 50 to 74 need routine mammograms every other year and that breast self-examinations shouldn’t be taught.) It created a political firestorm with many women screaming that the new guidelines were part of a medical plot against them and simply designed to save money without considering their health and indeed, their lives.

Fast forward to today, Election Day 2010, when the last thing certain candidates need is a massive revolt by any voter with a prostate.

Here’s how The Journal explains the great cancelled-meeting controversy:

We broke the story last week that the USPSTF had canceled the Nov. 1-2 meeting, which USPSTF Chairman Ned Calonge said was due to scheduling conflicts. He had no comment then on whether the proximity of the meeting to Election Day played any role in the decision. Emails sent this morning to Calonge, the AHRQ and Lin weren’t immediately returned.

Calonge told us last week he was hoping to have a conference call to “keep the work moving forward” and then reconvene again in March for the next regularly scheduled meeting. That should include a vote on prostate-cancer screening.

As we also reported last week, last November the USPSTF voted at first to give prostate-cancer screening a “D” recommendation for all age groups, meaning the group recommends against screening for all age groups. Currently the USPSTF has an “I” rating for prostate-cancer screening, which means the current evidence is insufficient to assess the balance of benefits and harms, for men younger than 75. For older men, the rating is “D.”