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Monday, June 25, 2007

Blog Updates - Q2 2007

There have been updates to many posts over the last quarter. Unfortunately due to a problem with blogger the entire list was lost (although the updates themselves were applied and not lost). I have tried to recall as many as I can but unfortunately its not very complete. To keep up to date on this blog its important to read through these updates. All the key information has been included with each one so that you do not have to refer back to the original post.

In the Urinary Incontinence post we mention:
  1. a 5 minute video on overactive bladder/urge incontinence which can be found here.
  2. a May 15, 2007 Urology Times article [link] in which Dr. Raz says that botlinum toxin may be an alternative to anticholinergic drugs for overactive bladder (associated with urge urinary incontinence).
  3. this 2007 human study of 23 patients on the effect of RTX on UUI showed that it was effective in about 2/3rds of subjects with refractory urgency (i.e. nothing works). Its not a cure but it reduces the number of episodes somewhat: [link]. Also see this 2004 animal study: [link] .
  4. which comments apply to stress urinary incontinence (SUI) and which to urge urinary incontinence (UUI) to make it clearer that surgery applies to SUI while drugs are used to treat UUI.

In PSA Screening and Early Detection - Part 2. Key Points on PSA we elaborate on the use of ultrasensitive testing after local treatment. The more sensitive tests are widely used in the US after surgery or radiation for earlier recognizition of rising PSA and earlier treatment intervention. Such intervention would typically be radiation after surgery if the disease were localized to the prostate bed or hormonal therapy if it were metastatic; however, even in these applications some countries such as Canada primarily use the less sensitive tests based on the idea that low levels of PSA are also consistent with indolent disease and one presumably wants confirmation that the disease is, in fact, presenting a danger to avoid unnecessary treatment for recurrence. Furthermore, if the cancer is metastatic then conventional thought has been that it is best to delay hormone treatment since such delay also delays the time that it becomes androgen independent and therefore presumably prolongs survival. On the other hand there is accumulating data that suggests that the actual situation is just the opposite -- early use of hormone therapy prolongs survival. See [PMID: 12667882] and [Full Text]. Also [link] based on [PMID: 17513807] outcomes of salvage RT were better if the PSA was below 0.6 when RT was performed. Of course if early use prolongs survival then there is an advantage to early detection and therefore to ultrasensitive PSA testing.

In PSA Screening and Early Detection. Part 3 - Current Environment we added
  1. guidelines from Malayasia. The letter after each guideline refers to the strength of the evidence supporting the guideline with A being strongest and E being weakest: All males above 40 years of age with the risk factor of having a first degree relative with prostate cancer diagnosed at a young age (<60 years) may be screened. (E), PSA should be used in combination with DRE to enhance early detection. (B), The improved sensitivity and specificity of age-specific PSA ranges is at best modest and, hence, not recommended. (C), PSA velocity (0.75 ng/ml/yr) has not improved the sensitivity and specificity of the test and is probably not useful as first line assessment for prostate cancer. (C), PSA density is not recommended as there is no improvement in the sensitivity and specificity over the PSA level. (B), Free to total PSA ratio is helpful as the sensitivity and specificity for detecting prostate cancer is higher in patients with a serum PSA level of between 4 and 10 ng/ml. (B), The optimal cut-off level is still being investigated. Population screening for prostate cancer among Malaysian men is not recommended. (E), The appropriate threshold serum PSA level for case detection is 4.0 ng/ml. (B), Volunteers and/or referred patients with abnormal PSA results and/or suspicious DRE are recommended to undergo prostate biopsy. (A), PSA is useful in monitoring response to treatment. (B), PSA is useful in detection of early recurrence. (B)

  2. guidelines from the National Comprehensive Cancer Network (NCCN). guidelines recommend that physicians offer testing starting at age 45 and repeat every 5 years if PSA < 0.6 and every year otherwise.

Added additional case histories to the Case Histories post.

In the post on Famous People with Prostate Cancer the primary link seems no longer to work and we provided an alternative [link] via the wayback machine.

In the How Healthy Men Can Reduce their Risk post, we cite a presentation at the 2007 ASCO Symposium by Neil Fleshner (who is also co-author of one of our free nutrition downloads, Prostate Cancer Nutrition and You listed in the right hand column of this blog). This presentation is primarily about recurrence rather than aimed at healthy individuals but the possibility exists it might apply and the results seem remarkable and have little downside if they do not pan out so we mention it. The results were shown in both mouse models and in human subjects consuming a combination of lycopene (50 mg/day), selenium (200 mcg/day) and vitamin E (800 IU/day). This combination virtually arrested prostate cancer development in mice and in humans brought about improvements in progression markers in only 4 weeks. The investigators determined that lycopene was the single most powerful factor of the three yet removing any one of the three resulted in significantly lower benefit. This might also have a potential benefit in the case of undetected or subclinical prostate cancer. The anticancer effect of AR5 inhibitors was also discussed.

In the post on Choosing a Surgeon - Part I. Considerations reference was added to a news release from Memorial Sloan Kettering reporting on a study which, consistent with the existing studies, found that patients who saw urologists tended to undergo surgery while those who saw urologists and radiation oncologists tended to undergo radiation.

In the Drug Pipeline post we added the following clinical trials information sites from other countries: Australia, Netherlands and Japan. Also see the International Standard Randomized Control Trial Number site: ISRCTN. The ISRCTN scheme is a simple numeric system for the unique identification of clinical trials worldwide. In addition to randomised controlled trials, the ISRCTN Register will also accept registration of other forms of studies designed to assess the efficacy of healthcare interventions. Its aim is to simplify the identification of trials and provide a unique number that can be used to track all publications and reports resulting from each trial. It is owned by ISRCTN - a not-for-profit organisation.

In the post on Historical Developments added reference to Robert Hastings -- the first nerve sparing patient. Also see Nerve Sparing Turns 25.

In Choosing a Surgeon - Part 1. Considerations we added reference to two NY Times articles about how US doctors have conflicting incentives which may cause some to choose treatments and procedures based on what makes most business sense to them rather than what makes most medical sense for the patient. See these June, 2007 NY Times articles: [NY Times link 1] and [NY Times link 2].

Revised the introductory material to the Canadian Cancer Society's recommendation 1000 IU of Vitamin D. In [link] the Canadian Cancer Society is recommending that all adult Canadians take 1000 IU of Vitamin D daily in fall and winter while those at higher risk of low Vitmain D levels take the same amount daily all year round. The importance of this is that it is the first major cancer organization to recommend daily Vitamin D supplementation as a population-wide anti-cancer prevention strategy. The Canadian Cancer Society later qualified their recommendation, saying to check with your doctor first. Since the announcement Vitamin D has been flying off the shelves and Jamieson, Canada's largest vitamin maker with a 40% share of the Vitamin D market has seen sales temporarily spike to 8x their normal volume. See this article from Report on Business
on Vitamin D sales in Canada and the Canadian Cancer Society's press release (link above).

In PSA Screening and Early Detection. Part 3. Current Environment the National Prostate Cancer Coalition points out that in the US only 28 states the District of Columbia mandate insurance coverage for PSA screening (compared to 49 states mandating insurance coverage for mammograms). See the page marked 4 (the 6th page of the PDF document) here. (The NPCC also issues a report card rating each state on a number dimensions -- mortality rates, screening Rates, co-signers for early detection legislation, co-signers for Department of Defense Cancer program, co-signers for Prostate Cancer Awareness Month resolution, mandating insurance coverage, AUA urologists per capita and clinical trial sites).