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Patient Handout: PSA Testing

I am sick of explaining PSA testing to my patients.  To get out of the inevitable questions about the pros, cons, science, and politics behind the new recommendations, I made the following handout.  Ironically, my laziness motivates me to do a whole bunch of stuff.  It kind of feels like I'm being tricked into doing extra work, but there's nobody to blame.  I'm just that way.  I guess I'm a sucker that way. Anyway, here it is.  Feel free to take advantage of my work to make your life easier.  I don't think there's any hope for me.

PSA Testing - Pro's and Cons

What is a PSA?  PSA is short for Prostate Specific Antigen and is a protein that is elevated in men who have prostate cancer.  PSA levels are tested using a blood test, and have up until recently been done yearly for all men over 50.  A “normal” PSA level is between 0 and 4, with numbers getting into the 100’s with prostate cancer.

What is the controversy about PSA testing?  The group of researchers and doctors who recommend testing have recently changed their recommendations.  In the past, all men over 50, and younger men with increased risk for prostate cancer were urged to get the test once a year.  This recommendation has been reversed, now only recommending PSA testing in men who either have had prostate cancer or who are at increased risk of developing it.

Why did they change this recommendation?  While PSA did reveal the presence of prostate cancer, studies have never reliably shown that average-risk men who get PSA tests live any longer than those who don’t.  This is especially true in men over age 65.

How could PSA not save lives if it helps find cancer?  There are several explanations for this:

  1. Prostate cancer is very slow-growing.  Studies of men in their 80’s revealed that a very high percentage of them had cancer in their prostate.  For older men it is now accepted that most men who get prostate cancer will die with it, not from it.
  2. Treatment for prostate cancer is not completely safe.  While some men were cured of prostate cancer by getting surgery and/or radiation, other men underwent these procedures, had long-term compilations, hospitalizations, and even death from the treatment.  When all of these were put together, the benefit of finding the cancer did not outweigh these negatives.
  3. Most elevated PSA tests are not because of cancer.

So how is prostate cancer diagnosed?  Unfortunately, there is no good test to screen for prostate cancer in average-risk men, just like there is no test to screen for brain tumors, pancreas cancer, or pneumonia.  Cancer is only diagnosed when it gets bad enough to give symptoms.

What are the symptoms of prostate cancer?  There are no consistent symptoms for prostate cancer.  Most symptoms from the prostate are from benign prostate enlargement (BPH), which doesn’t lead to cancer.

Should anyone get PSA testing?  Yes, men who have an increased risk (father or brother with prostate cancer) should still get it done yearly, as should men who have already had prostate cancer.  Most now agree that it’s not beneficial over age 65, but it is still controversial if average-risk men between 50 and 65 should be tested (urologists think so, but most researchers do not).

Why not just get tested “to be safe?”  A negative test is a good thing, and is reassuring that there is no cancer.  The problem is when the test is positive, as it really impossible to not aggressively treat it once it has been found.

Can men still get tested if they want?  Yes, but they should understand that doing so may lead them to get many procedures, surgery, radiation, and/or hospitalization, as well as side effects of treatment, such as impotence and incontinence.  All of these complications come without the assurance that they come with a longer life.  The bottom line is that we need a better test.

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I didn't say it in this handout, but I do have a theory as to who is behind the resistance to these recommendations:  it's the Lexus dealers and yacht manufacturers.  They have sold a bunch of cars and yachts to urologists on the income generated by PSA testing.  It makes sense.  It's all about the yachts.

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Patient Handout: Advance Directives

One of the big changes recently in my practice has been the addition of preventive care visits for Medicare patients (more on this later).  Of the greatest benefits has been the opportunity to talk about advance directives.  Because of this opportunity, I have talked about it far more than than ever before.  But because I am somewhat lazy, and I don't want' to give the same talk 1000 more times, I wrote my own handout about advance directives for my patients. I've decided that I will publish any handouts I write to my blog so that I can get comments from readers, and so that others can use what I have written for their own practice.

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Advance Directives: Living Wills and Health Care Power of Attorney

Nobody likes to think about them, but these two things are very important documents for people as they grow older.

What is a living will?

A Living Will answers the question: If I am incapacitated and can’t give my opinion, what do I want done if:

  1. My heart stops beating - do I want them to shock it to bring it back to beating?
  2. My breathing fails - do I want to be assisted in breathing using a ventilator?
  3. My blood pressure drops - do I want to get chemicals to raise my blood pressure?

For most people, the answers to these questions is, “Yes, as long as I won’t get stuck on a machine, and as long as things don’t get hopeless.”  In fact, this is the answer that doctors use if there is no living will at all.  Doctors aren’t forced to do everything at all cost to save a person, but they will do everything up to the point when it becomes clear that things are “hopeless.”

When is a living will important?

There are two circumstances when living will is most important:

  1. When a person doesn’t want any or all of the three things on the list done.
  2. When a person does want them done when other people might think they don’t.

These are often the case when people are elderly or have serious diseases that make life difficult.

Common Mistakes

  1. Not having a living will when it’s needed - This is bad, as it forces family to guess at what you would have wanted.
  2. Not understanding life-saving measures - Many people believe that being put on a “breathing machine” is a bad thing, and should always be avoided.  In truth, most people put on ventilators come off of them easily.  These are the same machines used to assist breathing during surgery, allowing deeper anesthesia.
  3. Not talking to family about this - People don’t like to talk about death, but avoiding this topic can turn a difficult situation into something that tears apart a family.

What is “Health care power of attorney?”

This is actually the more important decision to make, answering the question: “If I can’t make decisions about my health care, who should do it in my stead?”  If a person does not have this issue addressed, the law will assign people the task based on how close they are to the person.  The progression goes like this:

  1. Spouse (or parents, for an unmarried minor)
  2. Adult children
  3. Other next of kin, including adult grandchildren and siblings.

The problems happen when more than one person fits one of these categories.  If, for example, the spouse is not living or not available, all of the children will have equal rights to have their wishes followed.  In other words, the very difficult questions about a parent’s life and death are left to a committee of siblings, which can and has torn families apart.

How is it done?

Health care power of attorney is a designation of who you think will most keep with your wishes, and who will work best with the other family members.  It is a legal designation, and so should be overseen by an attorney if at all possible.  The process is as follows:

  1. Choose family member(s) that you feel confident with.  Choose a single person to have this responsibility and another (if possible) to take the role if the first can’t do it.
  2. Let them know that you are doing this and what your wishes are.
  3. Get the documentation (from an attorney or online - the AARP is a good resource for this kind of thing) and get it filled out, with proper witnesses and notarizing if needed.
  4. Put the documents in a place that is safe and is known to all involved

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Letter to Patients Regarding Pain Medications

It is one of the biggest struggles and least favorite areas of being a doctor, yet it is something I see far too much: patients taking short-acting narcotic pain medications for chronic pain.  There is a degree to which it a good thing, allowing people to get regular prescriptions of smaller amounts of pain medication to use for increases from their background pain; but far too many of them call for their prescriptions on the month, often asking for a little bit more this month because of increased pain. Many doctors see these people as "drug-seekers" - a description with a very bad connotation, implying that the medication is central, not the pain.  While I know there are drug-seekers out there, many of whom feign pain so they can get prescriptions and then make money selling it, there are also a lot of people with bad pain who want to escape.  In fact, I try to make that number 100%, as I want nobody lying to me to get medications they don't need or use.  Those phone calls every month for narcotics, often trying to get it a little early, get a stronger dose, or get more in each prescription, I think are people who really hurt and really think they need the medication.

But short-acting medications are a deal with the devil when used regularly for chronic pain.  They create more problems and much, much bigger problems than they treat.  So in response to this, I am starting to send the following letter to my patients who are using medications like this on a regular basis:

Dear <Patient>

I am sending this letter to patients who are using narcotic pain medications on a regular basis for chronic pain.  I am doing so, not as an accusation or a sermon, but to educate you as to the reasons use of medications in this setting is not only risky, it almost always will cause problems down the road when used for a chronic problem.  This also does not imply that I will not give prescriptions for these medications when you need them.  I will give pain medication for appropriate pain, but I will also do everything possible to minimize the use of short-acting pain medications.  What follows is an explanation as to why I think this is so important.

Chronic pain is pain that lasts for a long time - more than a month.  While it is OK to use short-acting pain medications (like hydrocodone or oxycodone) for short-lived pain (like that from an injury), it is not good use them regularly in long-term pain. •    It may work for a short while, but the body develops a tolerance, requiring the dose to go up to get the same effect. •    Going up on the dose will only work for a while, and then an even higher dose is required. •    Eventually the person with chronic pain will require very high doses of narcotic to get even a modest effect. •    Being at high doses like this comes at a cost: withdrawal.  A person on high-dose narcotics (especially short-acting ones) will always cause withdrawal when the medication is stopped.  Withdrawal from narcotics is far worse than the pain for which the medications were given. •    To avoid withdrawal, the person on short-acting narcotics must continue taking the medication, creating a dependency on the drug that is hard to escape, while at the same time offering little pain relief.  It’s a horrible trap. •    Additionally, patients who take large amounts of narcotics are often labelled as a “drug seeker” by any new doctor they see or hospital they visit.  If this happens, it is much less likely the person will be taken seriously by the medical professionals. •    Finally, the doctor prescribing pain medications in large quantities puts his/her career at risk by doing so.  Careless prescription writing invites abuse by patients - something that can cause a doctor’s license to practice medicine to be taken away, and may even result in criminal charges. It is good to be concerned about a person’s pain, prescribing short-acting pain medication for chronic pain only promises to add a new problem to the picture: dependency and addiction.  The life of a person with chronic pain is bad enough without the dependency on narcotics, so the use of these medications except on an “as needed” basis for break-through pain is to be avoided.

Can anything be done for the person with chronic pain?  Yes, but the expectation should not be that the pain will be eliminated; it will only be reduced.  Here are ways to deal with chronic pain without the regular use of short-acting narcotics: •    Some antidepressants and seizure medications can reduce the overall need for pain medication. •    Treating the underlying problem (back surgery, for example) can reduce pain. •    Injections of cortisone or local anesthetics, as well as procedures done to block pain by pain specialists can help in certain circumstances. •    Long-acting narcotics (like Oxycontin, MS-Contin, or Duragesic/Fentanyl patches) can be used to lower the overall pain level, allowing short-acting medications to be only used as needed for breakthrough pain.  This is much less likely to cause dependency, relieves pain better than short-acting medications alone, and uses less medication in the process.  These do, however, put the person at risk for withdrawal symptoms if stopped suddenly.

If none of these work?  The sad answer to that is that the person will have to live with the pain.  Adding short-acting medication may offer short-term relief from the pain, but the long-term problems it inflicts are far worse than any benefit they have.

I hope this helps you.  I always want to have my patients feel the least amount of pain possible, but there are some things that may seem like they help in the short-term, but really cause problems much larger than the original pain.  I will work with you to find ways to minimize the need for these medications.  You should do everything you can to use them sparingly.

Again, I am happy to take care of you, and this letter is an attempt to give you the best care I can.

Sincerely:

Robert Lamberts, MD

I don't want my patients to hurt, but I also don't want to be party to hurting them more - even with the best of intent.  I hope this letter helps them see.  I hate to tell some people that they just have to feel pain, but unfortunately that is usually a better option than these medications.

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