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Florida Doctor – Central magazine delivers updates on local medical happenings around Central Florida. We cover Orange, Seminole, Osceola counties and beyond. If you have an update you would like to include in an upcoming issue of the magazine, please email .(JavaScript must be enabled to view this email address).
By Richard Wall
When men shy away from prostate cancer screening and treatment, the women in their lives often help them face their fears and the facts
“Men are funny. A guy will come in for an enlarged prostate issue and he’ll say everything is good, everything is fine,” says Ali Kasraeian, M.D. “But his wife will give me this look, and say, ‘I don’t know what he’s talking about. He gets up 50 times a night. And when he’s in the bathroom, it starts and stops, starts and stops.’ You often get a lot more information from a woman,” explains Dr. Kasraeian, a urologist at Kasraeian Urology in Jacksonville who performs laparoscopic robotic surgery on prostate cancer patients.
The symptoms the wife described could be due to a benign enlarged prostate or prostate cancer. So giving that information to a doctor sooner rather than later can change a life. But too often, men simply ignore health problems.
“When these guys start coming in at age 55 for whatever reasons, they sort of open up a Pandora’s Box of medical problems,” explains Dr. Kasraeian. “If men start having problems and they are ignoring them, the woman in their life will notice it, specifically in prostate cancer. Men don’t want to talk about these things, but their wives can get them to address it.”
Get His Foot in the Door
Women, in general, are more used to regular health care visits from an early age, when they begin seeing their OB/GYN for a yearly Pap smear exam, say physicians. Women also are more attuned to keeping up with medical screenings, current treatments and information on good health.
“Women tend to be more proactive, men tend to be more reserved and reluctant to see healthcare providers,” says Marc H. Blasser, M.D., F.A.C.S., with Urology Associates of Northeast Florida, which is affiliated with Orange Park Medical Center. “With prostate cancer screening, one of the reasons men are reluctant to seek help might be their fear of complications from treatment, which may or may not be justified. Erectile dysfunction and incontinence are two big reasons men don’t come in and get checked. The women in the men’s lives can absolutely make the difference there.”
A man’s prostate naturally grows as he ages. An enlarged prostate, a non-cancerous condition known as benign prostatic hyperplasia, can squeeze the urethra, creating urinary problems. “That goes to the question of screening, because sometimes it’s hard to distinguish a benign hyperplasia from cancer,” says Winston Tan, M.D., Senior Consultant at Mayo Clinic Florida in Hematology/Oncology. “When there’s a question about that, it’s important to get a biopsy, especially if the doctor feels a nodule on the prostate.”
Dr. Tan says that men can protect the health of their prostate by not being obese and by eating a low-fat, high-vegetable diet, behaviors that lower the incidence of prostate cancer. The drug Finasteride, or Proscar, is a prostate cancer prevention agent for men at high risk. And the vaccine Provenge has shown to improve survival rates for men with late stage prostate cancer.
The National Cancer Institute lists the following symptoms that may be due to prostate cancer:
One in six men will get prostate cancer, yet the rate of recovery is quite high in relation to other cancers. “Around 80 to 85 percent of patients will be cured, meaning they won’t have to deal with the disease again in their lifetime,” says Dr. Tan. The earlier you catch it, the better the prospects for recovery. So screening is very important.
“Men just don’t like to be screened,” says Dr. Tan. “They feel that men are strong, and they don’t need to do something uncomfortable, and a digital rectal exam is uncomfortable.”
Dr. Tan says about a third of the men who see him for prostate health issues only come in because their wives, girlfriends, mothers or sisters have made them do it. Some women may be concerned that their encouragement to seek screening could be seen as nagging.
“I think the most important thing is the way communication is given,” says Dr. Tan. “As long as women communicate in a proper way with their husbands that it is important to get screened, and people in the community support that with education, that would be a win-win situation, and the husband will get screened.”
For a white male with no other risk factors, prostate cancer screening should begin at age 50, says Dr. Kasraeian. African Americans have a higher risk of prostate cancer and should start screenings at age 40, as should white males who have family members with prostate cancer or other cancers that share a similar gene, such as breast and colon cancer.
“Prostate cancer is very family history related, so couples should be talking about that prospect,” says Dr. Kasraeian. He recommends men get both a yearly Prostate Specific Antigen (PSA) lab test and a digital rectal exam. “You have to catch prostate cancer early, and I think knowledge is a key thing,” says Dr. Kasraeian. “And the wives and significant others play a role in keeping up with this information. Their supportive role in getting a man screened is vital.”
Help Him Pick Himself Up
Once a screening exam raises a red flag, a urologist may do a biopsy. Dr. Kasraeian says he may do an ultrasonic evaluation of the prostate to get a map of where they’ll do the biopsy. “The pathologists look at it and tell us whether the patient has cancer or not. Depending on what the stage and grade of cancer, we’ll make decisions on treatment.”
Men may not handle the news well. “With men, it is actually very hard for them to understand that they have cancer,” says Dr. Tan. “We encourage patients to have a second ear when they come for a visit, perhaps their wife or someone they know who can explain to them the treatment choices and the side effects of the treatment.”
Women can manage all the information and help men make smart decisions on treatment options. Some men become bewildered, traumatized and depressed after learning they have prostate cancer, which clouds their judgment.
“We have a psychologist on staff who helps a patient cope with the diagnosis,” says Dr. Tan, adding that Mayo Clinic takes a multi-disciplinary team approach to treatment. “The most important factor that affects the patient once diagnosed with prostate cancer is how they feel about the disease and how they are able to resume their usual functions after they get the treatment. We have a program to get the patients back to where they have been after the procedures.”
Dr. Kasraeian says they always try to bring a man’s wife in on diagnosis consultations, encouraging them to face prostate cancer like a team, just like they might face breast cancer together. “With prostate cancer, it’s not like having your appendix taken out with only one option. You have a myriad of options, from surgery (including what kind of surgery, open or laparoscopic robotic) to radiation therapy and seed implants. There’s a lot of information,” says Dr. Kasraeian, who practices with his father Ahmad H. Kasraeian, M.D. “The support from a woman at that time is a strong factor in how a man deals with prostate cancer.”
Prostate cancer is categorized in stages and grades, which have a bearing on the type of treatment. Surgical treatment can be radical prostatectomy, which is the removal of the prostate. Other standard radiation treatments are external beam radiation and seed implant treatment, known as brachytherapy. Androgen deprivation therapy is a hormonal treatment option that blocks testosterone. High frequency ultrasound and cryo therapy, which is basically freezing the tumor, are also options for smaller subsets of patients.
Another option for the treatment of prostate cancer, which is a slow-growing type of cancer, is to merely monitor the patient. “There is a lot of controversy there because of what we call the volubility of the disease,” explains Dr. Tan. “There is a group of prostate cancer that is quite indolent, meaning men have prostate cancer but they die from other conditions, heart disease, stroke, other things.”
Operating Under Outdated Assumptions
Most men worry about the terrible two side effects of prostate cancer treatment: incontinence and impotency. But times have changed, and men may be operating under false assumptions, something an informed wife can help correct. “People who get prostate cancer are 50, 60, 70, and they are relying on what they’ve heard in the past,” says Dr. Kasraeian. “They may not know the advances we’ve made in reducing the side effects and treating the cancer.”
Institutions like Mayo Clinic have patient education programs and are also working to develop new drugs and treatments. “We’re looking at preventing agents, at new drugs that can modify the disease and hopefully prolong the patient’s life,” says Dr. Tan. “We’re looking at how the different procedures and therapies will alter the patient’s quality of life. We are developing an intervention on how to improve the quality of life for our patients.”
And the terrible two are most often the central quality of life issues. “These very much involve the significant other,” says Dr. Kasraeian. He says the minimally invasive surgical techniques he uses help reduce those issues and result in less blood loss, shorter hospital stays and quicker recovery and return to daily activities.
“In the procedures we do with robotic and laparoscopic techniques, we’re doing nerve preservations and reconstructions. So we’re getting earlier return of continence, somewhere in the 90 percent range,” says Dr. Kasraeian, who adds that he’s one of the few doctors in the area using these techniques, which have advantages of increased precision, visualization and range of motion. “And in potency, we’re doing a better job of nerve preservation and penile rehabilitation, using medications, vacuum pumps and injections after surgery. With all those combined, we’re doing 60 to 80 percent return to potency two years after surgery.”
Dr. Blasser focuses on urinary prosthetics, such as an inflatable penile prosthesis and artificial urinary sphincter implants, and often treats other urologist’s patients for urinary and erectile dysfunction. “The penile prosthesis is designed to restore full erectile function and has outstanding success rates of over 90 percent,” says Dr. Blasser. “This changes a couple’s lives incredibly.”
Urinary problems can also alter a couple’s relationship and benefit from a woman’s initiative, as one of Dr. Blasser’s patients illustrates. “He was wearing five or six adult diapers a day, was homebound, wouldn’t go out because he was embarrassed, his clothing was always wet and he smelled,” relates Dr. Blasser. “He and his wife didn’t have any intimate contact, they slept in different rooms, didn’t go out on dates. Their whole lives were dysfunctional. She felt abandoned, and he was depressed. She got him to come in. We gave him an artificial sphincter, and now he’s 99 percent dry,” says Dr. Blasser, adding that prosthetic options aren’t for every prostate cancer patient. “He’s playing tennis again, he’s taking his wife out on dates, and they’re sleeping together. She says their marriage has been reborn. And it’s because she’s the one who got him to get help.”
By Elisabeth Handley
Today’s treatment options give chronic pain sufferers a chance for a normal life
Life with chronic pain is impossible to imagine unless you have suffered it personally. “I lived with chronic pain for 40 years,” says DeMont Seagrave. “Part of the pain is hereditary, but at 19 I cracked my sacrum in two places. Doctors thought I wouldn’t walk again.”
Seagrave did walk again. And he enjoyed a genuinely dynamic life that included nine years playing with the New York Yankees and two subsequent careers in construction and restaurant ownership. But finally the pain was so constant and intense that he had to give up his business. “I didn’t smile or laugh and was always a grouch. I couldn’t load the dishwasher without sitting in a chair,” he says.
Millions suffer similarly to Seagrave. In fact, the National Center for Health Statistics estimates 76.2 million people live with chronic pain, costing annually in healthcare and lost productivity nearly $100 billion.
Clearly, the impact of this issue is massive. But what is chronic pain exactly?
Chronic pain is often defined as pain lasting more than six months and by and large affects the neck, back and spine. Unfortunately, industry experts are coming to identify chronic pain as a disease in itself, separate from whatever medical condition is causing it.
On the bright side, there are numerous treatments available to diminish the pain, aside from reliance on highly-addictive narcotics. And in reality, the goal of any reputable pain management specialist is to reduce or even eliminate the need for narcotics altogether.
This may seem contradictory to what you may have heard or seen in the media about pain management clinics. The industry has gotten a bad reputation due to the emergence of “pill mills” – so-called pain clinics where patients are able to walk in and get prescription medications without producing medical records or having a physical exam. Operating just inside the law, these clinics are generally not owned by physicians. Some notorious facilities even have staff posing as doctors in white coats. They usually don’t take insurance and operate on a cash-only basis.
A loophole in state law had caused Florida to become the narcotic pusher of the East Coast. Pain clinics in Broward County alone distributed more than 6.5 million oxycodone pills in the last six months of 2008, which the Broward Sheriff’s Office estimates at nearly four pills for every Broward resident.
The field of pain management has grown widely in the past decade due to recent developments and techniques that enable patients to live less pain-filled, more productive lives, but unscrupulous opportunists have taken advantage of this growth to make money at the expense of patients’ health.
“Broward County has the highest units of oxycodone prescribed in the entire United States,” says Edward Dieguez, Jr. M.D., a pain management specialist for Flagler Hospital who has championed new legislation to put these charlatans out of business. “There are nine people per day dying of drug-related overdose in Florida.” (A 107 percent jump in two years.)
Dr. Dieguez and his colleagues were able to get passed SB462, which will effectively put the pill mills out of business with strict regulations on the prescription of narcotics and by establishing a database throughout the state of all medications prescribed to a given patient.
“The best thing about the bill is that legitimate patients who truly need medications and take them correctly will be able to get them without hesitation,” says Dieguez.
Treatments Abound
The best way to get to a reputable pain management clinic is to be referred by your primary care physician. Most legitimate clinics only take patients on referral and will require a battery of diagnostic tests to determine the source of your pain to best offer a treatment plan before they will ever write a prescription.
Patients are generally referred to a pain management specialist when their doctor, orthopedist or neurologist has determined that surgery, physical therapy and other medical treatments cannot reliably treat the pain.
“We do a complete history and physical exam, decide which diagnostic studies are required, x-ray, MRI, cat scan, etc., then establish a treatment plan,” says Claudio Vincenty, M.D., of the Jacksonville Spine Center. “Many parts of the spine can create problems, including disc herniation, compression fractures and bone spurs. The pain is typically a combination of these things.”
That treatment plan will be different for each individual patient and will probably involve a battery of modalities that work together to treat your pain most effectively. Some of these procedures are conducted by the pain specialist – called passive modalities – such as medications, massage and injections. Others are things you can do to help yourself like exercise (aerobic and weight-bearing) and mind-body techniques (yoga, hypnotherapy and psychotherapy).
Passive Modalities
The tools in the pain specialists’ toolbox of passive modalities are extensive. Trigger Point Injection is one of the most common, whereby a local anesthetic and steroid is injected directly into the trigger point (knots in the muscle that do not relax) usually in arms, legs, lower back and neck. The injection causes the trigger point to become inactive, alleviating the pain for several months at a time.
The older, more sophisticated brother of trigger point injections is the thoracic epidural steroid injection (like the epidural given during childbirth). The epidural space surrounds the spinal cord. A steroid-anesthetic mix is injected into it to reduce inflammation and pain.
An additional form of injection, known as RF neurotomies, apply radio frequencies directly to the nerve on the spinal column to heat and cauterize it, thus preventing it from sending the pain message to the brain. This treatment provides relief which lasts from six to 12 months.
Another innovative tool is surgical implants, of which there are two types. The first is Intrathecal Drug Delivery, more commonly known as a pain pumps. The pump (usually about one inch thick and three inches wide) is surgically implanted under the skin. Also implanted is a catheter to carry the medication from the pump to the intrathecal space around the spinal cord. While this method still uses narcotics to treat the pain, it is a fraction of the amount required with pills because it’s delivered directly to the origination site of the pain signal.
“Medications directed into spinal fluid take 1/100th of a dose of oral medications,” says Dr. Vincenty. “The side affects in terms of cognitive dysfunction associated with narcotics is virtually eliminated.”
The second type of implant is the Spinal Cord Stimulation Implant, in which a device is inserted in the body that delivers low-level electrical signals to the spinal cord or spinal nerves to prevent the pain message from getting to the brain. This device can be remotely controlled by the patient to turn it on or off and to adjust the intensity of the electrical signals.
DeMont Seagrave is a recent recipient of a spinal implant. “After the first four hours of the trial period, I knew this was for me,” he says. “I was pain-free for the first time in 40 years.”
Then there’s TENS, or transcutaneous electrical nerve stimulation therapy. This procedure utilizes electrodes placed on the skin near the pain source to deliver a low-voltage electrical current. This stimulates the nerves to scramble the normal pain signals to the brain. So far, TENS only provides short-term relief.
Physical therapy is also a key tool in pain management as it is designed to improve the movement and function of the affected area. Often, once other therapies have reduced the pain in the area, physical therapy is used to rebuild and prevent future pain. “We often continue physical therapy as part of a comprehensive program,” says Dr. Vincenty. “Once we get the pain under control, then patients can go back to physical therapy for strengthening and flexibility.”
Using Your Head
Many times, psychological treatment goes hand-in-hand with pain management. Pain can affect personality, wreck sleep and negatively affect work and relationships. Plus, the depression, anxiety and stress of dealing with the pain can make the pain worse. “Psychological problems are the proverbial chicken and the egg,” says Dr. Vincenty. “Patients often suffer from depression due to a total change in lifestyle, job loss, etc. caused by the pain. Pain specialists typically work with psychologists to develop coping skills, to prevent the continued downward spiral.”
Similarly, mind-body techniques such as meditation, guided imagery, biofeedback and hypnosis can teach a patient to use their own mind’s ability to control their body’s reaction to the pain. The belief is that through these “physiologic quieting techniques,” you can train your body to release chemicals that reduce your perception of the pain.
Alternative therapies are also gaining popularity in conjunction with treatments from Western medicine. One of the most common is acupuncture, which practitioners believe increases the release of endorphins, the chemicals that block pain. The needles are inserted to stimulate nerves, which in turn stimulate the muscle. That muscle sends a message to the central nervous system, telling it to release endorphins.
Dr. Dieguez, though trained as a traditional medical doctor, has in the past two years expanded his practice to include acupuncture. “I had a patient that I had tried everything for I could think of,” he says. “I sent her to the University of Florida where they suggested acupuncture.”
The woman saw an acupuncturist and ended up pain-free. This got Dieguez intrigued, so he took a course to get certified in acupuncture himself. “We don’t ignore Western medicine completely, but if we’ve tried several techniques for a patient without success, we’ll give them the acupuncture option.”
Other alternative techniques include chiropractic treatment, massage, therapeutic touch, reiki healing, nutritional supplements and dietary approaches to treating pain. While many patients do report relief from many of these techniques, long-term relief of chronic pain has yet to be proven by scientific tests. Though certainly anything that helps relieve stress or improve the overall health of a chronic pain patient can only aid the possible increase of the effectiveness of more traditional therapies.
As Dr. Dieguez says, “There’s not one magic bullet that makes all the pain go away forever. It doesn’t exist. Pain management is a process of finding which treatment works best for each patient.”
With the many treatment tools pain specialists have available in their toolbox, the vast majority of patients will find relief. And for those who’ve suffered with chronic pain for any extended period of time, it’s getting their former life back that’s the true relief.
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