Year: 2007

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A man with benign enlarged prostate gland – What are the treatment options?

A man has symptomatic benign enlargement of the prostate gland. What are his treatment options?

“Prostatic disease eventually affects almost all men; benign prostatic hypertrophy or hyperplasia (BPH) is an inevitable part of aging,” says an article in the Canadian Medical Association Journal (CMAJ June 19, 2007).

Do we need to worry about prostatic hypertrophy or hyperplasia which in simple terms means prostatic enlargement? Sure, we have to worry. Who knows, it could be malignant. Although prostatic enlargement eventually affects almost all aging men, not all men suffer from prostatic cancer. The lifetime risk of diagnosis of prostatic cancer is 18 per cent and death from prostatic cancer is three per cent.

Enlarged prostate gland has several effects. These include difficulty with voiding urine and blood PSA levels may go up. Other complications are urinary retention, urinary bleeding, bladder stones, recurrent urinary tract infections and renal failure. These effects become progressively worse requiring frequent medical attention and rising PSA requires multiple tests to rule out prostate cancer.

About 20 years ago, the standard treatment for benign enlargement of prostate gland was surgery. Now, patients with mild symptoms do not need any treatment. Patients with moderate symptoms are treated with medications. These medications have shown to improve the flow of urine and improve the quality of life. Do these medications prevent complications of BPH? Studies have shown that this is possible.

The two major classes of drugs used to treat BPH are: a) alpha-blockers like doxazosin relax smooth muscle fibers of the bladder neck and prostate gland to reduce prostatic obstruction, b) five- – reductase inhibitors like finasteride decrease levels of testosterone in the prostatic gland itself but do not affect the systemic testosterone level. This leads to reduction of the prostate gland by 20-30 per cent.

With -blockers, patients experience relief of symptom within two weeks of starting the medication, compared with several months with finasteride. Researchers have found that doxazosin and finasteride slowed down the growth of BPH compared with placebo; the combination therapy was significantly more effective than either drug alone.

The CMAJ article says that the Medical Therapy of Prostatic Symptoms study showed that:
-BPH is a progressive disease
-progression can be prevented by medical therapy
-patients at risk for progression can be readily identified by PSA level, prostatic volume and symptom severity
-and the combination of finasteride and doxazosin is more effective than either alone in preventing progression, particularly in high-risk groups.

Are there any side-effects to these medications?

The article says that clinically significant side effects, mainly postural hypotension (low blood pressure), were infrequent and they led to cessation of therapy in 18–27 per cent of the men involved in the study. Side effects that occurred were minor and related mainly to sexual function.

Patients treated with finasteride had significant benefit with improvement in urinary symptoms. There was also an added advantage in that the finasteride-treated patients saw reduction in the overall risk of prostate cancer by 25 per cent – a rate almost unheard of in the field of cancer prevention, says the CMAJ article. The authors of the article say, “Because PSA levels are reduced in men with BPH who are taking finasteride, rising PSA findings are more likely to be caused by prostate cancer. Taking this drug may therefore provide a diagnostic advantage as well.”

The article poses the question: Should selected patients now be offered finasteride to lower their risk of developing prostate cancer and BPH progression?

“The answer, based on these trials, is unequivocally yes,” conclude the authors of the CMAJ article.

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The Power of Sleep

Are we sleep deprived?

When I was at the peak of my career, I used to brag that I did not need more than five hours of sleep each night. I take power naps at least couple of times a day to keep me fresh and alert. I also brag about my capacity to dose off anywhere at any time in any position – even standing!

If you are a workaholic then your sleep habit is no better. It is estimated that one in six adults report getting less than six hours of sleep nightly. Work related stress is one reason. But there are several other reasons as well. Too much caffeine, nicotine and alcohol does not help. And 24-hour cable TV, the Internet and email also take a toll on our sleep.

A report in the Globe and Mail says that nearly eight in 10 married couples say their partner has a sleep problem, like snoring, insomnia, or incessant tossing and turning. A quarter say sleep difficulties force their mate into separate sleeping quarters. More than 20 per cent say they’re too sleepy for sex.

What happens if you don’t get enough sleep?
According to a large British study released few days ago, people who do not get enough sleep are more than twice as likely to die of heart disease. Researchers said lack of sleep appeared to be linked to increased blood pressure. We know that increased blood pressure raises the risk of heart attacks and stroke.

Previous reports have linked too little sleep to impaired memory and thought processes, depression and decreased immune response. Sleep deficits result in poor work performance, driving accidents, relationship problems, and mood problems like anger and depression. Diabetes and obesity have also been linked with chronic sleep loss.

How much sleep do we need?

Infants usually require about 16-18 hours of sleep per day, while teenagers need about 9 hours per day on average. Most adults need about seven to eight hours of sleep per day. The British researchers say that consistently sleeping around seven hours per night is optimal for health. When we sleep, the body rests and restores its energy levels. Good sleep is essential for our physical and mental well-being. A good night’s sleep will help us cope with stress, solve problems, or recover from illness.

Also be aware that the quality of sleep we get is as important as the quantity. Each morning, after seven to eight hours of sleep we feel tired and not fresh then it is a sign of poor quality sleep. If this is a chronic problem then you may be suffering from a sleep disorder which requires investigation and treatment. Your doctor can help you by referring you to a sleep clinic.

Remember, good sleep is just as important for overall health as diet and exercise. So Dr. B, stop bragging and start sleeping. The magic number is – seven hours.

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The Power of Vitamin D

Summer is almost over. Kids are back to school. I am back to writing my columns.

A friend wants to know: What should I make of all the news about vitamin D?

I said to him: If you haven’t started taking vitamin D everyday then you better talk to your doctor and start taking one. Talking to your doctor is important to make sure vitamin D is compatible with other medications you take.

We have always known vitamin D is needed for good health and strong bones and teeth. Your doctor will prescribe vitamin D supplements if you don’t get enough in your diet. Vitamin D is also used to treat rickets, low phosphate levels, and parathyroid problems.

In the last few months several reports have appeared which advance the case for universal intake of vitamin D on a daily basis.

A report published in the Journal of the American Geriatrics Society says vitamin D, taken in a high dose, may help prevent falls in the elderly. The study shows that nursing home residents who took a daily dose of 800 international units (IU) of vitamin D for five months were less likely to fall than those who took either lower doses or no vitamin D.

Another report appeared in the journal Nutrition Reviews suggests that adults should daily take 2,000 IU of vitamin D to help prevent some cancers.

The authors reviewed 29 observational studies and concluded that in North America, a projected 50 per cent reduction in colon and breast cancer incidence would require a universal intake of 2,000 to 3,500 IU per day of vitamin D.

A third report came out in the Archives of Internal Medicine. This review paper analyzed the results of 18 vitamin D studies says that taking vitamin D supplements may help people live longer. But it’s not yet clear exactly how vitamin D does that. But it appears to be a life extender.

So how much vitamin D should you take?

It has been previously determined that “adequate intake” of vitamin D is 200 IU per day for the first 50 years of life, 400 IU per day from 51-70, and 600 IU per day after age 71. Researchers now say that 2,000-IU daily dose of vitamin D is currently considered the “tolerable upper limit” for vitamin D. Most commercially available multivitamins contain between 400 and 600 IU.

The Canadian Cancer Society is now recommended taking 1,000 IU of vitamin D daily as a cancer prevention step. Experts suggest taking supplements of no more than 2,000 IU per day.

Some foods – for example, oily fish like salmon and sardines – are a natural source of the vitamin. Milk is commonly fortified with 100 IU per cup. The sun is the most potent source. When the sun’s ultraviolet rays hit the skin, the skin makes the vitamin, which is rapidly absorbed in the blood and can be stored for several months, mostly in the blood and fat tissue. However, excessive sun exposure is not recommended because of the well-known risk of skin cancer.

Are there any side effects if you take too much vitamin D?

Likely side effects are: Constipation, diarrhea, dry mouth, constant headache, thirst, metallic taste, irregular heartbeat, weakness, fatigue, loss of appetite, dry mouth, muscle pain, bone pain, irritability, nausea, and vomiting.

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Did you know…

Did you know the death rate for breast cancer for Canadian women has dropped by 25 per cent since 1986?

A Canadian Cancer Society special report in Canadian Statistics 2007 says increased participation in organized breast screening programs (particularly by women aged 50 to 69) has led to earlier detection and made it more likely that patients who have breast cancer receive successful treatment (CMAJ June 19, 2007).

The national recommendation is that organized breast cancer screening programs actively screen women aged 50 to 69 every two years. Organized screening programs began in British Columbia in 1988 and have since expanded to include all provinces, the Yukon and the Northwest Territories.

If you are under 50 years of age or 70 and over then discuss your risks and screening program with your physician.

The screening program includes mammogram, clinical examination of your breasts by your physician every two years and monthly breast self-examination.

Did you know that early diagnosis and treatment of prostate cancer was first suggested a century ago?

Although prostate-specific antigen (PSA) blood test has been widely used in North America to detect early prostate cancer, it is still unknown whether PSA screening significantly reduces mortality from prostate cancer.

Actually PSA measurements reflect cancer risk, with the risks of cancer and of aggressive cancer increasing with the level of PSA (CMAJ June 19, 2007). Besides PSA blood level, your physician will look at other risk factors before he can advise you on further management. Other risk factors are: family history of prostate cancer, digital rectal examination findings, age, ethnicity and history of previous biopsy with a negative result.

Since PSA test is not a perfect test for detecting early prostate cancer, you should discuss with your doctor the risks and benefits of ordering such a test. PSA blood test for screening is not recommended by the Canadian Task Force on Preventive Health Care as there is insufficient evidence to promote it for screening for early detection of prostate cancer. Canadian Urological Association and Prostate Cancer Alliance have recommended that it be performed only after detailed discussion of the pros and cons between doctor and patient.

What is interesting is that recent nationwide survey indicated that almost half of Canadian men over 50 years of age reported receiving PSA screening during their lifetime. PSA blood test and digital rectal examination have become part of annual physical examination for men over 50 by their family physician and 72 per cent of these men had these tests in the last one year (CMAJ).

Prostate cancer is thought to be the disease of older men. But autopsy studies have found that 27 per cent of men in their 30s and 34 per cent of men in their 40s have histological evidence of the disease (not necessarily clinically known disease). The current lifetime risk of disease diagnosis is 18 per cent and lifetime risk of dying from prostate cancer is three per cent.

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