Prostate, Prostate CA, BPH, and economics

There has been much written in the news lately about the prostate: prostate cancer, new guidelines for Dx. and Rx., robotic prostate surgery, and a recent article in Archives of Internal Medicine (vol 170, #5, 3/8/10, pp 451-452)by Dr. M. Barry.

Just as an aside, "regular" prostate surgery is generally done in less than 2 hours, and robotic surgery generally takes longer than 3 hours. If you undergo more than 2.5 hours Operating room time,the risk of complications rises sharply.

What it all boils down to is that THERE IS NO INCONTROVERTIBLE EVIDENCE THAT TREATING PROSTATE CANCER SAVES LIVES.This does not mean that every male with prostate cancer will die from the cancer, but only that no treatment has been shown to cure it. The only study that has not been done is to do quadrant biopsies on all males annually, beginning at age 40, and treating all cancers with a Gleason score of 3 or less. Once prostate cancer is diagnosed (prompted by a rectal exam or an elevated PSA) surveys have shown that your family doctor will often recommend watchful waiting, your urologist will most likely recommend surgery, and a radiation oncologist will most likely recommend radiation. Since there is no evidence that treatment saves lives, it is difficult to justify an annual PSA test, unless the patient agrees to treatment. And, based upon my office experience, his wife will never agree to watchful waiting, so send the lab results to his office.

Once the CA is treated, many men have a few months of urinary incontinence, and/or erectile dysfunction. This may last for 2 years, or be permanent. If the ED seems to be permanent, the most satisfying treatment seems to be to transplant the 12th rib to the center of the penis, so that the "erection" is permanent.

Since the prostate grows without limit, all men will eventually have symptoms of BPH, evidenced by having to get up at night to urinate, or reduction in urinary stream force,etc. The prescribed treatment is with selective alpha-blockers, and/or reductase inhibitors (Proscar, etc.)The newest selective alpha-blocker, which has the least effect on the ciliary artery and therefore is the safest vis-a-vis future cataract surgery, is Rapaflo, (silodosin) 4mg or 8mg at bedtime. Only the combination of a reductase inhibitor plus an alpha-blocker has been shown to reduce the future need for a TURP to open up the prostatic urethra. However, since the old TURP involved inserting a rotatable knife thru the penis and up to the prostate, much like a Roto-rooter operation, and the procedure is now relatively bloodless and pain-free when done with the "green light" laser, not all men opt for the two drugs, especially since Proscar and its relatives diminish the amount of seminal fluid that is ejaculated. One should also remember that alpha blockers can increase the amount of retrograde ejaculation, i.e. backwards into the bladder, rather than forward and out of the urethra.

As for economics, why do you think surgeons recommend surgery and radiators recommend radiation? This leads into the larger question of economics. It is somewhat paradoxical that in today's times, microeconomics would suggest that you save your money, while macroeconomics wants you to help America spend its way out of the recession.

As a former mathematical and experimental physicist, I have looked into the mathematics, models and predictions of all branches of economics, and they all have the same fallacy: They assume that humans are always rational, and never panic sell or binge buy. This is clearly not the case (cf. "The Madness of Crowds"), but since arbitrary,"irrational" behavior cannot be mathematically modeled, calculated or predicted, it is excluded from ALL economic mathematics and their models. When the Black-Scholes "Theorem" was used to model the portfolio of Long Term Capital Funding, it was implicit in their model that no major country would fail to support its own currency. No allowance was made for this occurrence because (a) its happening was abrupt and unpredictable, and (b) the results depended on which country forfeited its currency. Therefore, when Russia defaulted on the ruble, LTCF would have gone bankrupt to the tune of $4B, but the U.S. Gov't bailed them out.

I won't even go into the required nonlinearity of any market model,that is caused by feedback. What we are dealing with here is the drunkard looking under the lamppost for his lost auto keys because the light is better there, rather than in the dark up the block where he actually dropped them. (And no, I lost no money in the market plunge.) People feel more comfortable with a "prediction" created by mathematics, even though GIGO is operating on a huge scale. Now in physics, if the result of an experiment differs from that predicted by our model of the world, we change our model. But economists cannot change their models, because catastrophe theory is too difficult to be mathematically tractable enough to use for predictions (see Rene Thom's work on this problem).

There are and seemingly will always be market crashes, because it is impossible to predict their occurrence or their nature (?something similar to earthquake prediction). No matter what the model, it basically assumes that the past can be used to model the future. How a tulip bulb crash can model Penn Central or the crash of 1873 is not clear to me. It is the question of predicting individual economic behavior vs. mass economic behavior. We have the same problem in medicine. I have no problem recommending that 1,000,000 women have annual mammograms beginning at age ??, but I have 25 female patients over the age of 85 who have never had mammograms or breast cancer, and so far they are right, too.

Men, Enlarged Prostates, and Cataract Surgery

The purpose of this issue of my blog is to analyze and discuss a recent article in the Journal of the American Medical Association issue of the week of May 20, 2009: "Association Between Tamulosin (i.e. Flomax) and Serious Ophthalmic Adverse Events in Older Men Following Cataract Surgery", Bell, C.M. et. al., JAMA, vol. 301, pp. 1991-1996, 2009.

A very brief "summary" would suggest that all men with BPH who are on Flomax, 0.4 mg., 1 or 2 at bedtime, should ask their internist or urologist to switch them to Uroxatral, 10 mg. (and no, I do not receive any money from drug companies).

A short discussion of human anatomy and physiology is in order. The kidneys make urine continuously, which collects in the renal calyces and drains by peristaltic action through the bilateral ureters into the bladder. At the bottom of the bladder, the urine exits through the ureter. The ureter first passes through the prostate gland, which sits directly under the bladder, and then through the center of the penis to the outside world.

A few parts of the human body continue to grow throughout adult life. Some of these are the prostate gland, the tip of your nose (which is why witches are always pictures as having long, curved noses), your ears, ...Now the prostate has 3 lobes, the right, left and middle. Your physician examines and estimates the size of your prostate (and looks for prostate cancer) when he/she does a rectal exam. However, the middle lobe, which is almost impossible to feel or estimate, is the part that concerns us here. The urethra passes through the middle lobe, where it contains smooth muscle in its walls, which helps to maintain the urinary sphincter so that you don't dribble urine, or accidentally urinate when you are ejaculating sperm and seminal fluid.

As the prostate grows, the prostatic urethra slowly gets compressed, so that its diameter is functionally reduced. It then takes you longer to start urinating, and longer to complete urinating. It also makes it difficult to empty your bladder completely. Since you make approximately the same amount of urine each day, then if you can't empty your bladder as completely as you once did, then you have to empty it more often, in order to maintain the same 24 hour output to the outside world.

Often the earliest sign of this that is troubling to men is the awakening at night caused by the need to evacuate some urine. By the time a patient has to awaken two or three times, then quality of life generally enables them to agree to take medicine for this condition.

The lining of the smooth muscle walls of the urethra in the prostate contain alpha-receptors, as do the walls of blood vessels. Without going into overwhelming detail, stimulation of the alpha receptors (e.g. by nor-epinephrine, a hormone produced by the adrenal gland) causes the urethra to contract further. An alpha-blocker enables the prostatic urethra to relax. This permits a man to empty his bladder more completely, and therefore, usually, to sleep through the night or awaken no more than once. (I am not discussing the use of Proscar or Avodart here.)

Unfortunately, alpha (actually alpha-1) receptors are also present in the dilator muscle of the iris, as well as its arteriolar walls. Because of this, then alpha blocking can cause the "floppy iris syndrome" during and after cataract surgery. The conclusion of the article was that "exposure to tamulosin within 14 days of cataract surgery was significantly associated with serious post-operative ophthalmic events. There were no significant associations with exposure to other alpha-blocker medications used to treat BPH".

You will have to read the article yourself or discuss it with your ophthalmologist to help evaluate how this article applies to you. I have already switched all my Flomax patients to Uroxatral, and explained why. I have had some battles with HMO's over this, since Flomax is available in a generic form while Uroxatral is not.

Good Luck!