Today we start the process of evaluating your prostate cancer and making a decision on how best to treat it. For now at least you have options. For those unfortunate men in Canada, the UK and anywhere else where socialized medicine is the norm, you get what they tell you they will pay for. Think about that closely when you read about how President Obama and the Democratic Congress want to change health care. They will swear on a stack of bibles that it won’t happen, but rationing of care and restriction of choice is the backbone of a socialized medicine system. I know, as I worked in the US military for a decade. If you care about your ability to chose you doctor and your treatments, then make your voice heard. Otherwise you will find yourself with a major case of buyers’ remorse and the best medical care in the world will be compromised by the the talking heads in Congress and the White House who don’t have a clue about medicine or the delivery of medical care.
Depending upon your risk stratification, your evaluation after your diagnosis of prostate cancer may be minimal to quite involved. For the average man who is low risk (PSA < 10, Gleason’s sum 6 or less) very often no further evaluation is necessary.
Dr. Alan Partin of John’s Hopkins University Department of Urology has simplified what used to be rather tedious decision making. Based upon his research looking at thousands of patients, we can now give our patients their percentage risk for probability of having lymph node involvement or cancer outside of the confines of the prostate. This has obviated much of the testing that was traditionally done for patients diagnosed with prostate cancer.
Still, there are patients that will need further evaluation prior to making specific treatment decisions. If the PSA is high or the Gleason’s sum is over 6, many urologists will recommend obtaining a baseline whole body nuclear bone scan. Because one of the common landing sites for metastatic prostate cancer in the skeleton, a whole body nuclear bone scan will often help identify this aspect of disease before it ever becomes symptomatic. Again, for patients with high risk disease, some urologists will obtain abdomen and pelvic CT scans looking for obvious enlargement of the lymph nodes that “live” near the prostate gland. It needs to be understood that a CT scan is only good for finding gross enlargement of these lymph nodes and has no ability to pick up microscopic disease. The Prostatscint scan which is another test similar to the whole body nuclear bone scan which is more sensitive than either a bone scan or a CT scan but is not even close to being a “perfect” test for determining if the prostate cancer has spread past the confines of the prostate gland.
In most cases which are low risk, it is common to proceed directly to definitive management of the disease. All treatments of prostate cancer impact urinary function. Some treatment options which we will discuss in future blogs have more impact on voiding function than others. Because of this many urologists will recommend a urinary flow test and check of post void residual urine to get a better idea of the functional capacity of the lower urinary tract. Should this test be abnormal, cystoscopy, or endoscopic evaluation of the urethra, prostate and bladder would be the next logical step. A flow test is a non-invasive study that requires the patient to urinate in a machine which measure the peak an caliber of the urinary stream. While cystoscopy involves instrumentation of the urinary tract and is somewhat uncomfortable, for the majority of patients the test takes only a few minutes and can be done with local anesthesia rather than sedation or general anesthesia.
Our next discussion will outline all of the various options for treating prostate cancer. After that, we will go further in-depth into each of the ways that prostate cancer can be attacked.
Until then, enjoy your summer, tend your garden, cheer for the Orioles and keep your fingers crossed that the Ravens get Terrell Suggs signed before the July 15 deadline to the contract extension that he so richly deserves. (And rich he will be after signing it.)
Posted by .(JavaScript must be enabled to view this email address) on 06/28/09 at 08:44 PM | Comments (4)Comments
Dr. Leventhal made several serious errors in addressing the crisis in health care.
First, Americans do not have access to the best health care in the world unless they are among the small privileged class. Between the 44 million without health insurance, the more than 25 million who have very limited health insurance and those about to loose their coverage when they’re laid off, his claim holds no water.
He argues against single-payer health care. While private for-profit insurance takes as much as 30 cents from every dollar to give large salaries to executives and to pay dividends to stock-holders, Medicare takes less than 5 cents of every dollar for administrative costs and possible wasteful spending.
The proper role for government is to make primary health care available to everyone in this country. Leventhal cites Canada and England, where it is a felony to sell primary health care insurance for a profit. Canada provides quality primary care to everyone at a much lower cost than we do.
In a country where police and fire protection, national security and a first-class highway system are correctly funded by all for use by all, why should something like health, which is recognized by our constitution as an inalienable right, become a place for the wealthy to make a profit?
Posted by m. hyman on 08/15/09 at 09:52 AMThere is a difference between REAL logic, and URO-logic.
By his silly political comments (see refutation below), Dr. Leventhal has declared himself the official piss boy of the Maryland Republican Party.
Go with the flow, Doc!
Republicans Propagating Falsehoods in Attacks on Health-Care Reform
By Steven Pearlstein
Friday, August 7, 2009 Washington POST
As a columnist who regularly dishes out sharp criticism, I try not to question the motives of people with whom I don’t agree. Today, I’m going to step over that line.
The recent attacks by Republican leaders and their ideological fellow-travelers on the effort to reform the health-care system have been so misleading, so disingenuous, that they could only spring from a cynical effort to gain partisan political advantage. By poisoning the political well, they’ve given up any pretense of being the loyal opposition. They’ve become political terrorists, willing to say or do anything to prevent the country from reaching a consensus on one of its most serious domestic problems.
There are lots of valid criticisms that can be made against the health reform plans moving through Congress—I’ve made a few myself. But there is no credible way to look at what has been proposed by the president or any congressional committee and conclude that these will result in a government takeover of the health-care system. That is a flat-out lie whose only purpose is to scare the public and stop political conversation.
Under any plan likely to emerge from Congress, the vast majority of Americans who are not old or poor will continue to buy health insurance from private companies, continue to get their health care from doctors in private practice and continue to be treated at privately owned hospitals.
The centerpiece of all the plans is a new health insurance exchange set up by the government where individuals, small businesses and eventually larger businesses will be able to purchase insurance from private insurers at lower rates than are now generally available under rules that require insurers to offer coverage to anyone regardless of health condition. Low-income workers buying insurance through the exchange—along with their employers—would be eligible for government subsidies. While the government will take a more active role in regulating the insurance market and increase its spending for health care, that hardly amounts to the kind of government-run system that critics conjure up when they trot out that oh-so-clever line about the Department of Motor Vehicles being in charge of your colonoscopy.
There is still a vigorous debate as to whether one of the insurance options offered through those exchanges would be a government-run insurance company of some sort. There are now less-than-even odds that such a public option will survive in the Senate, while even House leaders have agreed that the public plan won’t be able to piggy-back on Medicare. So the probability that a public-run insurance plan is about to drive every private insurer out of business—the Republican nightmare scenario—is approximately zero.
By now, you’ve probably also heard that health reform will cost taxpayers at least a trillion dollars. Another lie.
First of all, that’s not a trillion every year, as most people assume—it’s a trillion over 10 years, which is the silly way that people in Washington talk about federal budgets. On an annual basis, that translates to about $140 billion, when things are up and running.
Even that, however, grossly overstates the net cost to the government of providing universal coverage. Other parts of the reform plan would result in offsetting savings for Medicare: reductions in unnecessary subsidies to private insurers, in annual increases in payments rates for doctors and in payments to hospitals for providing free care to the uninsured. The net increase in government spending for health care would likely be about $100 billion a year, a one-time increase equal to less than 1 percent of a national income that grows at an average rate of 2.5 percent every year.
The Republican lies about the economics of health reform are also heavily laced with hypocrisy.
While holding themselves out as paragons of fiscal rectitude, Republicans grandstand against just about every idea to reduce the amount of health care people consume or the prices paid to health-care providers—the only two ways I can think of to credibly bring health spending under control.
When Democrats, for example, propose to fund research to give doctors, patients and health plans better information on what works and what doesn’t, Republicans sense a sinister plot to have the government decide what treatments you will get. By the same wacko-logic, a proposal that Medicare pay for counseling on end-of-life care is transformed into a secret plan for mass euthanasia of the elderly.
Government negotiation on drug prices? The end of medical innovation as we know it, according to the GOP’s Dr. No. Reduce Medicare payments to overpriced specialists and inefficient hospitals? The first step on the slippery slope toward rationing.
Can there be anyone more two-faced than the Republican leaders who in one breath rail against the evils of government-run health care and in another propose a government-subsidized high-risk pool for people with chronic illness, government-subsidized community health centers for the uninsured, and opening up Medicare to people at age 55?
Health reform is a test of whether this country can function once again as a civil society—whether we can trust ourselves to embrace the big, important changes that require everyone to give up something in order to make everyone better off. Republican leaders are eager to see us fail that test. We need to show them that no matter how many lies they tell or how many scare tactics they concoct, Americans will come together and get this done.
If health reform is to be anyone’s Waterloo, let it be theirs.
——
A Canadian Doctor Diagnoses US Health Care
Monday 03 August 2009
by: Michael M. Rachlis | Visit article original @ The Los Angeles Times
Canadian hospitals, which operate under a universal health program, offer the same opportunities for surgery as American hospitals - despite the fact that no candidates for surgery are denied for financial reasons. (Photo: Artur Bergman / flickr)
The caricature of “socialized medicine” is used by corporate interests to confuse Americans and maintain their bottom lines instead of patients’ health.
Universal health insurance is on the American policy agenda for the fifth time since World War II. In the 1960s, the U.S. chose public coverage for only the elderly and the very poor, while Canada opted for a universal program for hospitals and physicians’ services. As a policy analyst, I know there are lessons to be learned from studying the effect of different approaches in similar jurisdictions. But, as a Canadian with lots of American friends and relatives, I am saddened that Americans seem incapable of learning them.
Our countries are joined at the hip. We peacefully share a continent, a British heritage of representative government and now ownership of GM. And, until 50 years ago, we had similar health systems, healthcare costs and vital statistics.
The U.S.’ and Canada’s different health insurance decisions make up the world’s largest health policy experiment. And the results?
On coverage, all Canadians have insurance for hospital and physician services. There are no deductibles or co-pays. Most provinces also provide coverage for programs for home care, long-term care, pharmaceuticals and durable medical equipment, although there are co-pays.
On the U.S. side, 46 million people have no insurance, millions are underinsured and healthcare bills bankrupt more than 1 million Americans every year.
Lesson No. 1: A single-payer system would eliminate most U.S. coverage problems.
On costs, Canada spends 10% of its economy on healthcare; the U.S. spends 16%. The extra 6% of GDP amounts to more than $800 billion per year. The spending gap between the two nations is almost entirely because of higher overhead. Canadians don’t need thousands of actuaries to set premiums or thousands of lawyers to deny care. Even the U.S. Medicare program has 80% to 90% lower administrative costs than private Medicare Advantage policies. And providers and suppliers can’t charge as much when they have to deal with a single payer.
Lessons No. 2 and 3: Single-payer systems reduce duplicative administrative costs and can negotiate lower prices.
Because most of the difference in spending is for non-patient care, Canadians actually get more of most services. We see the doctor more often and take more drugs. We even have more lung transplant surgery. We do get less heart surgery, but not so much less that we are any more likely to die of heart attacks. And we now live nearly three years longer, and our infant mortality is 20% lower.
Lesson No. 4: Single-payer plans can deliver the goods because their funding goes to services, not overhead.
The Canadian system does have its problems, and these also provide important lessons. Notwithstanding a few well-publicized and misleading cases, Canadians needing urgent care get immediate treatment. But we do wait too long for much elective care, including appointments with family doctors and specialists and selected surgical procedures. We also do a poor job managing chronic disease.
However, according to the New York-based Commonwealth Fund, both the American and the Canadian systems fare badly in these areas. In fact, an April U.S. Government Accountability Office report noted that U.S. emergency room wait times have increased, and patients who should be seen immediately are now waiting an average of 28 minutes. The GAO has also raised concerns about two- to four-month waiting times for mammograms.
On closer examination, most of these problems have little to do with public insurance or even overall resources. Despite the delays, the GAO said there is enough mammogram capacity.
These problems are largely caused by our shared politico-cultural barriers to quality of care. In 19th century North America, doctors waged a campaign against quacks and snake-oil salesmen and attained a legislative monopoly on medical practice. In return, they promised to set and enforce standards of practice. By and large, it didn’t happen. And perverse incentives like fee-for-service make things even worse.
Using techniques like those championed by the Boston-based Institute for Healthcare Improvement, providers can eliminate most delays. In Hamilton, Ontario, 17 psychiatrists have linked up with 100 family doctors and 80 social workers to offer some of the world’s best access to mental health services. And in Toronto, simple process improvements mean you can now get your hip assessed in one week and get a new one, if you need it, within a month.
Lesson No. 5: Canadian healthcare delivery problems have nothing to do with our single-payer system and can be fixed by re-engineering for quality.
U.S. health policy would be miles ahead if policymakers could learn these lessons. But they seem less interested in Canada’s, or any other nation’s, experience than ever. Why?
American democracy runs on money. Pharmaceutical and insurance companies have the fuel. Analysts see hundreds of billions of premiums wasted on overhead that could fund care for the uninsured. But industry executives and shareholders see bonuses and dividends.
Compounding the confusion is traditional American ignorance of what happens north of the border, which makes it easy to mislead people. Boilerplate anti-government rhetoric does the same. The U.S. media, legislators and even presidents have claimed that our “socialized” system doesn’t let us choose our own doctors. In fact, Canadians have free choice of physicians. It’s Americans these days who are restricted to “in-plan” doctors.
Unfortunately, many Americans won’t get to hear the straight goods because vested interests are promoting a caricature of the Canadian experience.
————-
Michael M. Rachlis is a physician, health policy analyst and author in Toronto.
Cut out the right-wing Bible-thumping political partisan politiking crap. And your sophomoric sports commentary. This is supposed to be A MEDICAL column, NOT a political (or sports) one.
In your case, what does “M.D.” stand for? Malpractice Defendant?
As an army urologist, was your motto “Pee all that you can pee” ?
Posted by j. m, reynolds on 08/08/09 at 09:27 AMI just read your Jewish Times blog on prostate cancer.
We should talk.
I am a prostate cancer survivor who had probably the best treatment available today for prostate cancer:
proton beam therapy which is highly targeted radiation using protons instead of photons, thus greatly reducing
my chances of suffering from either of the two major side effects associated with treatments for prostate cancer:
incontinence and impotence. I suffer from neither. I was treated successfully in 2006.
My PSA before treatment was 4.0 and my Gleason score was 3+3=6. My dad was diagnosed about 8 years ago
and had seed implants. My first cousin died from prostate cancer at age 63 two years ago.
My PSA now is 0.9 and has been going down gradually over the last 3 years.
My treatment was in Loma Linda, CA at the Loma Linda University Medical Center’s Proton Center.
There are now 5 other centers across the country that provide this treatment with about 20 more being built.
The best website on all of this is http://www.protonbob.com There you can read a ton of testimonials including mine (the last one)
by people from all over the US and even beyond. Check it out.
The question is how will Obama’s socialized medicine affect one’s ability to get this great treatment.
Please call me - let’s talk.
Allan Kaufman
Owings Mills, MD 21117
410-363-0080
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