What a fascinating past couple of weeks. The Orioles bring up Matt Wieters and Jason Berkin. It looks like Brad Bergesen can pitch. A-roid is back with the Yankees and playing at a high level until it comes to the playoffs. And finally we have the rebirth of the “Open the JCC on Shabbat,” argument. So much to talk about, its hard to concentrate on prostate cancer. I hope that I do not offend anyone, but I will throw in my two cents.

For millennia, it has been said that the Jews kept the Shabbos. Actually, the reverse is true. It is Shabbos that kept the Jews. All one has to do is look at assimilation rates amongst people who are Shabbos observant versus non-observant and you will see the truth. And while I would never tell someone how to practice religion, I do feel that as a community it would be a bad precedent to have our own Jewish Community Center open on Shabbos in violation of the fourth of the ten commandments. It is not some minor law. It is part of ten major laws given to our people by our Creator. Again, I would never tell anyone how they should practice, Lord knows I have enough to work on myself to keep me busy for the rest of my life and then some. But the rest of the world looks to us. And when they see us make a statement which approves of violating our own commandments, they take notice, and not in a good way. Anyway, I’ll get off the soapbox and back to urology.

“Come on in Mr. Cohenthalstein and have a seat. We need to discuss your biopsy. Unfortunately today, I have both bad and good news. The bad news is that your biopsy was positive. The good news is that with today’s techniques of treatment and your risk profile, which we are about to discuss, I really believe that you have a great chance of being cured of your prostate cancer.”

This is the way the discussion begins in my office. The first thing I do is let the patient know the diagnosis. As I have said before, I much prefer doing this in person. My father was told he had cancer over the phone many years ago and I thought it was a terrible way to break someone that kind of news.

Today we are going to discuss risk stratification. The first thing we need to do is look at the patient’s PSA. In general, if the PSA is under ten, that puts the patient at low risk. Under four is even better, however, the most common presentation is for a PSA to be between six and ten.

The second factor I look at is called the Gleason sum. This is to be differentiated from the Gleason score. Basically, the pathologist looks under the microscope and finds the most prevalent pattern of cancer glands. He gives this a score of one to five. He then finds the second most prevalent pattern of glands and again gives this a score of one to five. He adds the two together and you get a Gleason sum which obviously can range from two to ten. I have never seen a two, three, or four. In my career, I have seen a small handful of fives. About 80% of men fall in at six. Ten percent are a seven and then the last ten percent are eight through ten. The higher the score the higher the risk. You want to be a six and if you are that makes you low risk. High risk would be an eight through ten, and seven is controversial.

The third factor I review is volume of disease. If I told you that of the ten biopsies we performed, every one was positive and in each core biopsy there was a lot of cancer it would lead you to the conclusion that you had high volume disease. If you had only one small piece of one core which was positive, it would be considered to be low volume disease. In general, low volume disease is lower risk and high volume disease is higher risk. Remember please that these are generalities.

So in conclusion, we have a few ways to determine what is your risk stratification. Your PSA, Gleason’s sum, and disease volume are all factors in helping to determine if your prostate cancer is considered low risk, moderate risk, or high risk. In our next discussion we will talk about further evaluation needed to help determine the best course of action for your prostate cancer. Remember, the bad news is that you have the disease. The good news is that if you are low risk, as most people are, you stand a great chance of beating the most common cancer in men and the leading cause of cancer deaths in men. Until next time…. Go O’s.

Sorry I have been inactive for so long but Passover and business issues kept me from working on the blog. I realize it’s a bad excuse, but it is the only one I have and hopefully one you will accept.

First lets cover the Ravens draft.  While I was hoping for a receiver to show up on draft day, I was very satisfied with the work done by The Wizard of Oz, Eric DeCosta and the rest of the gang at 1 Winning Drive. We needed a long term solution at right tackle and got it in Michael Oher who not only can play, but is a great human interest story. Paul Kruger, our second round pick, reminds me of a young Michael McCrary. Hopefully he will do so on the field. The rest of the draft filled needs with Ravens type ball players. Once again, Ozzie has proven why he is one of the top GM’s in the business. Hopefully the NFL will fail to notice DeCosta for a long time, because I think he is a large part of the process.

Now onto the results of the biopsy.

Today is going to be easy. Your biopsy that caused so much heartache when we discussed it oh so many weeks ago has come out benign. That means not cancerous. Typically, I have a patient come in to discuss biopsy results. I really hate giving bad news over the phone. I think it is very impersonal and I would not want to receive a cancer diagnosis that way. So everyone benign and malignant comes in for the news.

Often the biopsy is purely benign. In other words, there are no other findings. In this case, I will tell the patient that he should come back in six months for another PSA and rectal exam. After a benign biopsy, I will see a patient every 6 months for about 18 months to get some more PSA data points for each patient’s PSA graph. That way we will know if, “the trend is your friend.” If the PSA remains steady very often I will just follow the PSA. If the trend is upwards, I will often recommend a repeat biopsy. There was a study done at University of Michigan that showed that the likelihood of missing a significant prostate cancer with one set of random biopsies is 20 - 25%. This drops to about 4 - 5% with a second set of biopsies. Hence my willingness to recommend repeat biopsies.

Often the biopsy will show evidence of acute or chronic inflammation or both. This in and of itself, is enough to raise PSA. For this person, I will often recommend an extended course of antibiotics. This will often run 4 - 6 weeks and afterward a PSA will be obtained. I would like to see the PSA be driven down by antibiotic treatment. It makes me feel a whole lot better about the histologic findings of inflammation being the cause of the PSA elevation.

Occasionally, the results will show atypia or something call PIN which stands for Prostatic Intraepithelial Neoplasia. Neither of these are cancer but both can be harbingers of cancer. Typically recommended is repeat biopsy or close followup of the PSA.

Finally, for the avant-garde guy who wants to be proactive about his prostate health, I will often recommend dietary changes or nutritional supplements to promote the growth of healthy prostate tissues. Soy isoflavins, tomato lycopene, selenium, Vitamin D and E, Fish Oil are all compounds that have been purported to aid in prostate health. My feeling is that they can’t hurt you (as long as done in moderation) and that they may well help you. I consider these type of treatments investments in your health. You benefit by doing it, but I don’t think you are hurting yourself if you defer.

That’s it for today. I am working on the later discussions which will be all about your diagnosis if your biopsy is G-d forbid positive for prostate cancer. Until then, enjoy the spring, plant your tomatoes to get your tomato lycopene, and wait for Ravens Camp to start.