Prostate Cancer Screening

My patient was told in 1984 that he had prostate cancer and it would likely kill him within 5 years.  I wasn't the one who told him.  I was playing football as a senior in high school and more interested in putting people on their hind-quarters than examining them. I still had no clue I would even be a physician at that point.  But our eventual crossing of paths was set. 

In 1984 a diagnosis of prostate cancer usually meant only a 4% chance of cure. Currently, rates of 80-90% are common to cure prostate cancer.  The difference is a screening test called the Prostatic Specific Antigen, or PSA, which was developed by T. Ming Chu, PhD, DSc and his team in the 1970's at Roswell Park Cancer Institute in Buffalo, New York.  It was their specific goal to isolate a blood test for screening. They did exactly that. 

The PSA was released to monitor prostate cancer treatment effectiveness in 1986 and in 1994 it was approved as a screening test. There are many opinions on when, or even if, the test should be done from many different medical groups.   

My patient, and I'll call him Gary, was a stubborn sort of man and in 1984 he was 75 years old and not ready to die.  He actually vowed to his doctor that he would see his 95th birthday.  His doctor didn't really see it as realistic.  

When I met him in 2000 he was weaker, thin, had a lot of pain, and a lot of urinary infections from the cancer metastasis.  He still had steely, blue eyes and told me he would see his 95th birthday.  I admitted him to the hospital one night in 2002 just sure that his infection which was throughout his unconscious body would take him during the night.  I walked in the next morning to see him sitting up, eating eggs, and with a smile said, "Hey, Doc!"

Knowing the vastness of the tumors in his body it was unbelievable to see how he fought.  His mind was sharp, even sending me an article from Scientific American on the forefront of cancer treatment one month before he died.  He wanted to know if it could be developed in time for him.  

He passed three months after his 95th birthday, in his hospital bed in the home he built by hand on top of his mountain looking out the window at Mt. LeConte. I am certain he lived at least ten years on his will alone.  That's the power of the mind in the face of adversity.

Which is why I completely disagreed with the U.S. Preventive Services Task Force (USPSTF) recommendation on PSA screening that came out recently.  The USPSTF states “that there is moderate to high certainty that PSA testing has no net benefit or that harms outweigh benefits.”

Briefly, their reasoning is the too many false positive tests are causing too many biopsies and that the screening really doesn't extend life for those with diagnosed prostate cancer. 

Really? I truly believe this panel of experts (which did not include any primary care physicians) has "over-thunk" the problem.  The improvement in the cure rate alone should be enough of a counter-argument. 

The one thing that this talented, educated, number crunching, data extracting committee cannot measure is the power of knowing and the fear and anxiety of not knowing.  How does a data based decision weigh the emotions of a human mind? Medicine deals with people who have emotions, not an industrial process where a designed metal stamp produces one size fits all.  

I advise my male patients by age 50 to be screened for prostate cancer including the blood test and digital rectal exam (which usually should take less than 15 seconds) if they want it.  Some men decline.  Some don't.  All of their wives insist on it if for no other reason but to get even for the PAP tests they have had to endure. 

Family history, symptoms and race can prompt earlier screenings, but in my opinion, knowing what one is dealing with is better than not knowing anything at all.  That is the power of the mind and will meeting the options and methods of treatment.  Give the patient the chance to make the decision - and the consequences. 

It is another example of how computers, computing, and healthcare by a committee may have a role in our data driven society, but cannot, and never should, replace the patient-physician conversation, decision and treatment.  

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.

Testing for the High in Tennessee High Schools

One of my very first vivid memories of high school football was sitting in a small wooden desk in Miss Poole’s first grade classroom.  She started that Friday morning introducing our guests who were stopping by.  

Two of the guests were Harriman High School Senior Cheerleaders in uniform accompanied by two huge, smiling, football players wearing their actual game jerseys with jeans.  They were selling tickets to the ballgame that night and did we want to buy any? We, mere little first graders, were too awestruck to even say a word as they smiled, thanked us, and left.

They were bigger than movie stars in our eyes and they actually came to see us.  We had the money the next week and actually got to stand close to the cheerleaders and catch a whiff of their perfume as they gave us our tickets. They were true celebrities.  We wanted to be just like them. 

It is still that way.  Elementary and intermediate school children still look up to the high school athletes, cheerleaders and band members with a sense of wonder.  You can see it as the players take the field on Friday nights when little boys stand in a line just to ‘give five’ to the players and get really excited if a player says anything to them.  You can see it in the little girls who wear uniforms and stand with the high school cheerleaders as they cheer.  You can see it in the kids who sit close to the band and watch as they play during the game.  

I remember lying on the grass at a home football game as a senior stretching before the game quietly thinking and enjoying the aromas of fresh cut grass, hot chocolate, popcorn, and fall leaves.  I looked over to see a little boy standing with his dad at the fence watching the big high school players who were going to battle for his city that night.  The memories of being in first grade came storming back as I remembered how I looked at them.  It made me want to play better. We sent Midway home very unhappy that night. 

It makes a lasting impact how the high school players behave, smile, work, play, and represent their school and community - not just on the children watching, but most of all, the athlete. 

The TSSAA governs high school athletics in Tennessee.  When I played there was not much intervention unless you really did something stupid. We got a letter for our fight after the game with Sweetwater (lost the game, won the fight). 

Now the TSSAA has taken a much larger role in managing the games and especially the safety of the athletes.  Coaches must strictly adhere to temperature and humidity readings kept during practice instead of judging the temperature by how many players passed out that day.  Concussion management has also become a large topic of concern for the safety of the athletes, both in the short term and long term consequences.  

Concussions have been linked to unusual behaviour, poor judgement, impaired performance in class, memory loss, emotional outburst and depression as well as long term concerns for poor mental function.   

But so does drug usage. 

A six year study released in 2013 from The Partnership for Drug Free New Jersey showed “when a student was randomly drug tested, those students were much less likely to abuse and to experiment with drugs throughout their highs school careers,” according to  Angelo Valente, executive director of the partnership.

New Jersey has had many districts implement drug screening as part of granting the privilege to participate in extracurricular activities such as sports, dances, and even being allowed to park on campus. It has proven to be a deterrent.  It is a policy supported by the Supreme Court in Board of Education v. Earls in 2002.  

It is time for random drug screening at least once per season for every athlete under the TSSAA’s authority.  For football, a ten game season means ten percent of the players are randomly tested per week and the results turned in to the officials on Friday night.   The athletic directors and officials already meet prior to each game to discuss sportsmanship.  Why not add drug-free compliance? 

A search of the TSSAA website for “drug screening” yields “Sorry, nothing found. Please try again with a different keyword.” The TSSAA sponsors are clearly seen, including Blue Cross/Blue Shield of Tennessee who posted record profits in 2013.  Blue Cross/Blue Shield and another sponsor, Farmer’s Insurance, might actually find it a worthy investment to financially support drug random drug screening for TSSAA athletes in order to deter potential costs from poor choices while under the influence. 

Positive tests would involve a meeting and counseling with parents and a reduction in privileges.  Further positive tests would significantly reduce privileges.  The athletes would then have a reason, or out, to push back against peer pressure.  Or a reason to avoid a party with drugs.  Or a reason to focus on the rare opportunity to compete and excel athletically and to make better choices. 

Drug usage went on when I was in high school.  I remember the players who were talented but when the pressure was on to lead and perform, they couldn't handle it and hid under the apron strings of drugs.  A safety on an opposing team was much larger and stronger than me but his eyes gave him away.  His helmet was on, but no one was home.  I wore him out that night when he could have dominated me. He never got his scholarship.  No college wanted to put up with him. 

Drug usage goes on in every high school and the ones close to any team know about it.  No school wants to move on this issue alone, so then they should all move as one. The coaches I have talked to across the state quietly support the idea, but they believe it should be all teams, not just a few. 

The athlete’s future may depend on it.  

And the children, who look up to them, are watching. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.