I lied in the headline.

strawberriesA prostate biopsy is not actually fun. But if you need one – if your PSA has gone up more than 0.4 ng/ml a year, or if your doctor has felt something suspicious, like a hard spot on the prostate during the rectal exam – then you need one, so here are a few things you should know.

The way doctors look for cancer in the prostate is much like looking with a needle in a haystack. The needle in this case is a spring-loaded biopsy gun, a tiny device that’s attached to an ultrasound machine. It’s not like a sewing needle; this one has a hollow center, so that it can capture at least 10 to 12 tiny cores of tissue, each one about a millimeter thick. Those cores go to a pathologist, who studies them under the microscope.

The Seeds in the Strawberry

What are they looking for? Johns Hopkins urologist Patrick Walsh, my co-author of Dr. Patrick Walsh‘s Guide to Surviving Prostate Cancer, uses this image with his patients: Imagine the prostate as a large strawberry.

Prostate cancer is multifocal. It causes what scientists call a field change. Multiple tumors pop up like dandelions, all at about the same time.

These seeds are tumors, and three to seven is the average number of separate cancers found in a radical prostatectomy (the operation to remove the entire prostate) specimen. How can a man develop several different spots of cancer? Prostate cancer is multifocal. It causes what scientists call a “field change” – basically, the entire prostate undergoes a transformation. Multiple tumors pop up like dandelions, all at about the same time. Each spot can be millimeters in size.

So this is what the urologist is looking for with the biopsy needle. But it’s not easy to hit a tiny seed inside a strawberry, especially one you can’t always see.

Why Cancer Can be Missed in African American Men

In another post, I mentioned the important work that another urologist, Ted Schaeffer, M.D., Ph.D., chairman of urology at Northwestern, is doing in understanding how prostate cancer is different in African American men. One reason it may be more aggressive when it’s diagnosed is that black men with prostate cancer make less PSA per gram of cancerous tissue, “So their PSA score could be misleading,” says Schaeffer. “There are fewer early warning signs.”

But even when an African American man does get a biopsy, his cancer can be missed. This is because his cancer, for some ornery reason, picks the hardest-to-get-to, easiest-to-miss-on-a-biopsy region of the prostate. “The way I explain it to patients,” says Schaeffer, “is, think about your prostate like a house.

“You have a basement. Just under that basement, the sub-basement, is the rectum, where we do the biopsies. You have a first floor, and an attic. Tumors in most Caucasians occur in the basement. If you’re taking tissue samples of the prostate from the sub-basement, you can get a good sampling of that area and are more likely to pick up a cancer. But if you’re African American, you have a high chance of having what we call an anterior tumor, in the attic of the house. It’s just harder, frankly, to be able to sample that area on a standard biopsy.”

This is why Schaeffer and colleagues get MRI images of their patients at highest risk, including African American men. “If we see something suspicious, we do an MRI-guided biopsy. We’re not the only place in the world doing this, but we’re doing it for reasons that were discovered at Hopkins.”

So, this is what I hope will be the take-home message:

If you are a black man, you need to be checked for prostate cancer starting at age 40. Get a baseline PSA test and have a rectal exam. If your PSA goes up more than 0.4 ng/ml a year – even if the number itself is low – you need a biopsy. Ideally, you need an MRI-guided biopsy. If no cancer is found, and that PSA keeps going up, you need another biopsy. If your doctor does not feel this way, find another one – a doctor who understands that prostate cancer is different in African American men in several important ways.

And Now, a Word About the Bacteria in Your Rear End

No offense, but you have bacteria in your bottom. We all do, so it’s nothing personal here. But it becomes an issue, so to speak, when you need a prostate biopsy. You’ve probably heard of nasty bugs known as multi-drug-resistant bacteria. When the biopsy needle goes into the prostate, it goes “transrectally” – through the rectum. To minimize the risk of infection, the standard protocol is for men to have an enema and to take antibiotics.

But this is not always enough. It turns out that one out of every five men has this multi-drug-resistant bacteria. If you have it, and you get an infection, “you can get very sick,” says Ted Schaeffer. The men most at risk? “Diabetics and health care providers. He made this observation in a study of a huge Medicare database of patients. His father, noted urologist Anthony J. Schaeffer, Urologist-in-Chief at Northwestern, is an expert on infection. Together, they came up with a protocol to lower the risk of a bad infection. “Before any biopsy, we sample the rectal flora” – the butt bacteria, if you will – with a simple swab test. “If we detect resistant bacteria, we then appropriately modify the antibiotic we give before the biopsy. That’s very important, because we’re preventing infectious complications that could be life-threatening.”

Before your biopsy, talk to your doctor about the risk of infection, and whether it would be possible to get a simple swab test ahead of time.

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington


self portaitIf you are a man of African American descent – or a woman who loves him — I hope you read this. You are in the group that is hit the hardest by prostate cancer of all men in the world.

When you look at the men at highest risk of getting prostate cancer, one risk factor that stands out is having a family history of the disease – a father,brother, grandfather, or uncle, on either your mother’s or your father’s side of the family.

The other one is being black.

There are a bunch of reasons for this, including genetic differences in the androgen receptor, and lower levels of vitamin D, and diet, and socioeconomic differences in medical care, and some other things in the book I co-wrote with the great Johns Hopkins surgeon/scientist Patrick Walsh, called Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer. But those things – while certainly important, and of potential help for researchers trying to treat or prevent the disease in the future — don’t even really matter to you right now.

[Tweet “When African American men are diagnosed with prostate cancer, it is likely to be a more aggressive form of cancer.”]

What you need to know is that when African American (AA) men are diagnosed with prostate cancer, it is likely to be a more aggressive form of cancer. You are more likely to need to go after that cancer – if I were your relative, I would tell you not even to think about watchful waiting, or active surveillance, or whatever a doctor might call getting a repeat biopsy 6 months to a year later, and continuing to watch that PSA. You can’t do that, because prostate cancer is most likely different in you, and you need to take it very seriously.

I recently interviewed Ted Schaeffer, M.D., Ph.D., Director of the Johns Hopkins Brady Urological Institute’s Prostate Cancer Program, for a publication called Johns Hopkins Urology. (Note: Schaeffer is now chairman of urology at Northwestern.) A few years ago, Schaeffer made some important observations about the differences in cancer between men of African ancestry and other men. He followed up on them with research, he is the leader in this field, still actively researching this, and his findings are saving lives in the AA community.

“African American men often present with more aggressive cancers than other men,” says Schaeffer. For example, if you are an African American man who has been diagnosed with Gleason 6 (a stage of cancer that is often treated successfully and cured) disease, you have “a one-third higher chance of having more aggressive cancer than the biopsy suggests.” Also, “we found that when these men have surgery, they have a higher likelihood of needing additional adjuvant treatment.” These findings, published in the journal, Urology, were based on the outcomes of more than 17,000 men who underwent radical prostatectomy at Johns Hopkins; 1,650 of them were of African ancestry and were not only more likely to have a higher-grade cancer and larger tumors, but to experience recurrence of cancer compared to Caucasian men.

This is particularly worrisome in a time of confusing medical information, when many men and their doctors worry about overtreatment of prostate cancer, about side effects from surgery or radiation that didn’t need to happen, because maybe that disease would never have progressed, and a man could have lived his whole life without the cancer ever causing a problem. Yes, there are lucky men like this, and in a future post we’ll talk about what the criteria are for safely watching cancer, instead of taking it out or blasting the crap out of it with radiation. If you are a black man, you are most likely not one of these lucky men. I’m sorry, but you just aren’t, and I want you to know that so you can do something about it.

Schaeffer initially found that AA men who could be candidates for active surveillance turned out to have a much higher chance of having aggressive disease if they later needed surgery. He and colleagues later proved in the surveillance group that “the chance of failing surveillance or being reclassified
(determining that the cancer is a different stage or grade than initially thought) is 30 percent higher for black men compared to white men. We also found that even after surgery, if you control for the grade and stage of the cancer,men of African ancestry are more likely to have their cancers come back. It
means that biologically, they’re probably different.”

Cancer tends to develop in a harder-to-biopsy, easier-to-miss part of the prostate in black men than in other men. I’m going to write more about this in the next post, but the take-home message here is this:

If you are a black man, and you’re age 40 and you haven’t had your PSA checked and you haven’t had a rectal exam to check for prostate cancer, you need to do it.

You don’t want to get a rectal exam? Please. Don’t tell me, or any woman who’s had kids, where it’s like a train station in the hospital exam and everyone’s looking up inside you, that you don’t want to get that exam. It’s not that bad, and it can save your life.

If you are getting regular PSA exams and your PSA is going up consistently, more than 0.4 ng/ml a year (say you have one test and it’s a 1.4. The next year, it’s 1.9, then 2.5), you should get a biopsy. Don’t look at the overall number. PSA hasn’t been around that long, and at first, doctors thought that a PSA lower than 4.0 was okay; unfortunately, they missed a lot of cancers with just a basic cutoff number, because all men are different, and many factors, such as a man’s age and the size of his prostate, can affect that number. Ted Schaeffer would tell you that you should get an MRI-guided biopsy, because the MRI can pick up cancers that the biopsy misses.

If cancer is found, you need to treat it. Not with herbs, or dietary changes, or exercise, or supplements, or watchful waiting. Seek curative, aggressive treatment.

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In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington


300_200_hard_workI may not know you personally, but I know that, because you’re a man, chances are good that you do two things. One, you most likely respond to health issues with denial. I can relate to this – I do it, too.

And two, when things get tough, you just put your head down and keep going. You work harder, trying to take care of your family and not let anyone down at your job. Trust me on this, because I know and love the men in my family who do these same things:

[Tweet “You need a vacation. Time off. Relaxation. Your body needs it.”]

A famous neurosurgeon in Baltimore, when he used to interview residents, would ask them to show him something they had made with their hands. He did this because he knew how demanding the job was, how much pressure there was, and that being able to relax and take the time to tinker, or play a musical instrument, or whittle, or work on a car, not only calms you down and boosts your mental health, it can help you live longer and keep you healthier. A study from the Mind-Body Center at the University of Pittsburgh, of nearly 1,400 people who were taking part in other health studies, found that people who had more leisure activities had more satisfaction in life, found more meaning, were more spiritual, and basically just more positive in general. And that’s just down time, which we all need. But we also need to kick it up a notch and take actual vacations.

The Framingham Heart Study is a long-term study, started in 1948 in Framingham, Massachusetts, by what’s now the National Heart, Lung and Blood Institute. Over the years, they have followed thousands of participants, three generations of families who come back every two years for laboratory tests, a history and physical. Among their many important findings over the years was this one, from a study that looked at the effects of vacations in more than 12,000 men over a nine-year period. Men who didn t take vacations for several years had a 21-percent higher likelihood of dying, and were 32 percent more likely to have a heart attack than men who got away from work for at least one week a year. There was a definitive link between taking vacations and living longer, and staying healthier. The more vacations a man took, the longer he lived. Not taking a vacation doesn’t mean that you are going to have a heart attack, but it does mean that your risk of having one is most likely going up a little bit.

Does this mean you need to spend a lot of money to go on a cruise, or stay in a fancy hotel? Heck, no! But it does mean that you need to shut off the working guy for a few days, ideally a week, and be the relaxing guy. Resist the urge to check your work e-mail and phone messages! Resist it as if your life depends on it. Go fishing. Read a book. Wander around a museum, if that floats your boat. Or float in a real-life boat! Go to the movies, take a hike, play golf, go see a baseball game. Lie on a blanket and watch the clouds roll by. Whatever you do, do something you enjoy, and do it for several days straight. You have to break the cycle of lifestyle stress – commuting to work, being stressed at work, being stressed when you come home at family issues and all the things you need to do around the house, not
sleeping well – at least once a year.

We’ll talk more about stress in future posts, but when you get stressed, among other bad things that happen, your body makes a hormone called cortisol. Cortisol sucks. It ages you faster, and also makes your waistline thicker. When our ancestors were running away from mammoths or something equally horrible, their bodies produced cortisol and adrenaline. We still do, too. The adrenaline fades, but the cortisol makes our bodies think, as our Stone Age ancestors might have, “Maybe there’ll be no more food! I’d better eat while I can!” And when we eat in this situation, that weight tends to stay right in the worst possible place for heart attack risk – the belly.

When you come back from your vacation, chances are good that you will be more productive and that you’ll have a mental cushion that will protect you from burnout. Even if you get all stressed out the minute you walk back in the office and see 500 e-mails and a big pile of work. Dont worry, that s okay! You will have that cushion, and it will protect you, even if the glow of vacation is fading faster than the poster of Farrah Fawcett that used to hang up in your bedroom when you were a kid. Look at it this way: Say you have a great night’s sleep. You’re going to get tired again the next day, but that doesn’t mean that your body didn’t benefit from the good, healing sleep you had. It’s like recharging a battery. It’s money in the bank.

We Americans are mostly bad at taking vacations. In Europe, many employers give at least three weeks, and in France, many people take off for an entire month. In America, if we’re lucky, we get maybe two weeks, and one study done by the Families and Work Institute found that fewer than half of us use all of our allotted vacation days. Working parents, for instance, hoard them, so they can be there for their kids if they are sick. I’ve done it, and I can tell you that, although it’s a blessing to be there for your child, that’s not a vacation!

I would add that, when you plan your trip, don’t try to do too much. Ambition here is not what you need. Also, if you have a job that just wont give you a whole week off at once, you can still help your body and mind by taking more breaks, a weekend here and there.

Finally, I would like to leave you with the very sad case of Li Yuan, a Chinese advertising executive who died of a heart attack at age 24. For the entire month before he died, he had been staying late at the office, working until nearly midnight. A report from China said that more than 600,000 workers in that country die of exhaustion every year. That is just so wrong. Don’t be that guy. Take care of yourself.

©Janet Farrar Worthington