Blog Updates for October 2009

Oct 26/09. Added AUA/ASCO AR5 Inhibitors 2009 guideline to Guidelines-US line of the Links box in the right margin: [AUA/ASCO AR5 Inhibitors 2009]

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Oct 26/09. Added AUA PSA guidelines for 2009 on the Guidelines-US line of the Links box in the right margin: [AUA PSA 2009]

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Oct 11/09. Added [Rachlis] blog to the blog line of the Links box in the right margin. Writer is a Canadian physician who discusses US vs. Canadian health care. He provides interesting links to quality control and health care. He has written two books on the subject.

Blog Updates for September 2009

Sep 28, 2009. In PSA Screening and Early Detection - Part 5. More Diagnostic Testing Concepts we added another example:
A 2009 meta analysis of PSA testing [PMID: 1974436] summarized various studies on PSA accuracy with the following table:

	Study	Year	No	TP	FP	FN	TN	Sensitivity	Specificity
1	Aragona	2005	3171	1073	1695	98	305	0.92	0.15
2	Beneduce	2007	101	42	31	8	20	0.84	0.39
3	Ciatto	2004	410	167	171	18	54	0.90	0.24
4	Espana	1998	170	53	96	15	6	0.78	0.06
5	Fischer	2005	178	61	76	13	28	0.82	0.27
6	Hofer	2000	184	67	81	7	33	0.91	0.29
7	McArdle	2004	171	93	52	10	16	0.90	0.24
8	Ryden	2007	361	180	146	8	27	0.96	0.16
9	Unal	2000	59	30	10	0	19	1.00	0.66
10	Wymenga	2000	716	253	228	68	15	0.79	0.06

In terms of our previous 2x2 tables, for each study the TP (true positive) and FP (false positive) entries form the first row of the 2x2 table for that study and the FN (false negative) and TN (true negative) form the bottom row. In this notation Sensitivity = TP / (TP + FN) and Specificity = TN /(TN + FP) so that for example in the first row we have Sensitivity = TP / (TP + FN) = 1073 / (1073 + 98) = 0.92 and Specificity = TN /(TN + FP) = 305 / ( 305 + 1695 ) = 0.15 .

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Sep 5/09. In Prostate Cancer Calculators we added: This [site] describes how to carry out and calculate your fitness using the US Marines Fitness Test.

Blog Updates for August 2009

Aug 14. On the Case Histories page we added: PCA International has 6 videos by medical personnel and patients here.

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Aug 14. In How Healthy Men Can Reduce Their Risk we added: A 2009 review of prostate cancer screening and prevention by Eric Klein (papers) of the Cleveland Clinic is available here: [Full Text] [PMID: 19652036].

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Aug 14. In How Healthy Men Can Reduce Their Risk we added: Eric Klein (papers) of the Cleveland Clinic recommends biopsy to his patients if this risk calculator assesses the risk of prostate cancer to exceed 10%. See this paper: [Full Text] [PMID: 19652036].

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Aug 14. In Prostate Cancer Calculators we added: Risk prior to biopsy. In this paper: Eric Klein (papers) of the Cleveland Clinic recommends biopsy to his patients if this risk calculator assesses the risk of prostate cancer to exceed 10%: [Full Text] [PMID: 19652036]. The calculator gives risk of prostate cancer and risk of advanced prostate cancer given: Race, Age, PSA level in ng/ml, Family History of Prostate Cancer, Digital Rectal Examination results, Prior Prostate Biopsy and whether the patient is taking finasteride.

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Aug 3. Updated the Guidelines line of the Links box to the right to point to a more recent version of the:
ASCO guidelines

Blog Updates for July 2009

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July 24/09. In Biochemical PSA Recurrence we added: Local Recurrence vs. Systemic Disease. Local recurrence refers to rising PSA without further spread of the disease (i.e. without metastases). If the disease has spread then it is referred to as systemic. At the 2009 ASCO meeting John Hopkins researchers reported on a 25 year follow up to patients who had surgery and subsequent recurrence. They found that PSA doubling time (PSADT), Gleason score, and time to PSA progression were "strong independent predictors of metastasis-free survival". Of the patients experiencing recurrence, patients with with PSADT of less than 3 months, 9 months and 15 months had 20x, 6.3x and 2.4x the risk of systemic disease relative to those whose PSADT was longer respectively. Also patients with a Gleason score of 8 or more had double the risk of those with a lower Gleason score. Those for whom progression was evidenced within 3 years of surgery had roughly 3x the risk of those whose recurrence occurred later than 3 years. See [abstract] and [Science Daily News]. For more about PSADT see this [4 part post on PSADT]. (Note that the ratios (20x, etc.) described above were actually hazard ratios rather than relative risks. [PMID: 15273082] [Free Full Text]. To take the example of Gleason scores, the hazard ratio of 2 cited means that the odds that a patient with recurrence and Gleason score of at least 8, say, exhibits systemic disease before a patient with recurrence and a lower Gleason score is 2. Hazard ratios measure relative risk but are not necessarily numerically equal to the relative risk. See references just cited for details.)

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July 23/09. In Prostate Cancer Calculators we added:
PSA Velocity. This site provides a raw PSA velocity as well as one adjusted for hemodilution (i.e. taking into account a lower than otherwise PSA value due dilution in a large amount of blood normally associated with obesity). The PSA Velocity Calculator is also mentioned in this Medical News Today article.

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July 9/09. In AUA 2007 Conference Summaries we added: There is a video summary by Christopher Logothetis ((papers) of the 2009 ASCO highlights here.

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July 1/09. In Links to the right on the Benchmarking line we added a link
to a Barron's blog post on US government efforts to assess cost effectiveness of medical treatments: [Costs]

Blog Updates for June 2009

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June 16/09.
Added to Free Monthly Prostate Cancer Magazines and Journals these lists of free medical journals (not necessarily in the field of urology):

NHS (UK)
http://www.library.nhs.uk/Default.aspx

NIH - Pubmed Central (US)
http://www.pubmedcentral.nih.gov/fprender.fcgi

Biomed Central
http://www.biomedcentral.com/browse/journals

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June 16/09. On the Case Histories page we added: surgery takes effect immediately and also has the worst side effects immediately whereas radiation has relatively benign immediate side effects in the short term but over the following 24 months as the radiation kills the prostate cancer cells the side effects kick in [PMID: 19395191].

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June 7/09. On the Calculators page we added:
Wolfram Alpha provides a box in which you enter a query and find out where among the population you stand on various medical tests, e.g. enter one of these:
psa 5 age 60
vitamin d 25 age 60 male
bmi 25 age 60 male
life expectancy age 60 male
blood pressure 125/75 age 60 male
ldl cholesterol 125 age 60 male
hdl cholesterol 50 age 60 male
or if you omit the test value then it gives the population reference range, e.g. enter:
psa age 60

Blog Updates for May 2009

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May 25/09. On the Calculators page we added: Castrate Resistant Prostate Cancer. This calculator answers the question of whether the patient has castrate resistant prostate cancer and what the optimal treatment is. In association with this calculator readers may wish to view this presentation by Nicholas Vogelzang (papers).

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May 10/09. In Advice to the Newly Diagnosed we added: Major medical centers routinely circulate news releases on highly limited human studies (uncontrolled interventions, small samples [< 30], surrogate primary outcomes or unpublished data) yet in a study of 40 such releases "58% lacked the relevant cautions". [PMID: 19414840] [Full Text]. Journalists then uncritically report on them.

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May 8/09. In How Healthy Men Can Reduce Their Risk we added: In a 2005 review of the data from 50,000 men in the Health Professionals study, Harvard researchers found that those with the highest level of physical activity had only one third of the rate of advanced prostate cancer relative to those at the lowest level of physical activity (after adjusting for risk factors such as BMI, etc.). Also those at the highest physical activity level had only 26% the rate of fatal prostate cancer relative to those at the lowest level. The benefit only applied to those at the highest level of physical activity. Also the overall overall prostate cancer rates were not reduced but it did reduce advanced and fatal rates. See [PMID: 15883238] [Full Text].

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May 7/09. In Testosterone Metabolism and Prostate Cancer we added: A May 2009 study [PMID: 19414838] found "a significant statistical association between patients' eventual death from prostate cancer and abnormal expression (using protein staining) of "bcl-2", which regulates cell death, or of the "p53" tumor suppressor gene. Similarly, high microvessel density (the number of small blood vessels in the tumor) from biopsy specimens taken at diagnosis was also associated with an increased risk of death over 11 to 16 years." [summary].

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May 6/09. In Bradford Hill Criteria of Causation we added: A 2007 paper in PLoS Medicine estimated that 40% of all medical papers published were shaped behind the scenes by pharmaceutical companies in a process the paper refers to the ghost management (which is not the same as ghost writing). See [PMID: 17896859] [Full Text].

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May 4/09. In Lymph Node Dissection added: A 2009 review of Lymph Node Dissection in European Urology is available in [PMID: 19297079] [Full Text]. Note the tables in particular in this last review.

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May 1/09. In Advice to the Newly Diagnosed we added: This Yananow article Elephant in the Room by Terry Herbert has further statistics and information on outlook.

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May 1/09. In PSA Screening and Early Detection. Part 3. Current Environment we added: Since the above was written the AUA Best Practices Statement has been released. A [summary] is available as well.

Blog Updates for April 2009

Apr 23/09/. In ED After Prostatectomy. Part 2 - Rehabilitation we add a reference to this Feb. 2009 paper in the Canadian Urological Association Journal: [PMID: 19293974] [Full Text] which reviews rehabilitation.

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Apr 23/09. In Choosing a Surgeon - Part I. Considerations, Choosing a Surgeon - Part I. Considerations we added: Different primary care physicians have different approaches toward PSA testing [PMID: 19296843 ].

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Apr 20/09. On the Calculators page under SWOP the link has changed and risk indicators 3-6 are no longer present.

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Apr 24/09. In RP vs. LRP vs. RLRP - Part 4. What Surgeons and Others Say: Maurice Anidjar (papers) provides the following table (slightly abbreviated here) in Our Voice vol. 14 No. 1 pg. 10 (2009):

	Open	Laparascopic	Robotic
Incision	Mideline abdominal opening from pubic bone to navel	4-5 tiny incisions in the lower abdomen	5-6 small lower abdominal incisions
Blood Loss	About 700 ml	Average 400 ml	150 ml
Duration of procedure	2.5 hours	2 hours	2 hours
Recovery	bladder catheter in place for at least 2 weeks; in-hospital recovery usually 4 days; convalescence up to 6 weeks	Catheter removed after 4-7 days; less pain; shorter hospital stay (2 days) and convalescence (4 weeks)	Catheter usually removed after 7 days; shortest hospital stay (1 day)
Continence	As high as 90% at 1 year	Long-term results at least equivalent to those reported with open surgery	Recovery of urinary control appears to be earlier than with open surgery
Potency	Depending on nerve-sparing, can be up to 85%; takes 18 months or longer	Long-term results at least equivalent to those reported with open surgery	Results at least equivalent to best results from open and laparascopic approaches
Surgeon skills involved	Measured by ability to eliminate the entire tumor and preserve patient's continence and potency	Major learning curve reuired for surgeon to master the technique	Shorter learning curve than with laparascopic surgery

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Apr 24/09. In Radiation risks associated with Prostate Cancer we added: A study presented at the April 2009 American Roentgen Ray Society meeting based on 100 physician surveys in various specialities found that 63% underestimated radiation exposure from abdominal-pelvic CT scans and only 20% thought that radiation risk was a part of disclosure. See this PSA Rising article.