The Fight Against Cancer Never Rests. Northwestern’s Rebecca Blank and WXRT’s Lin Brehmer Have Revealed Their Battles.

Rebecca Blank and Lin Brehmer (Photos courtesy of Chicago Tribune)

Two days this week, two announcements that saddened me, one of which really shook me.

A 1975 Northwestern graduate, I wear the purple proudly. A family trip to Ryan Field for a football game is an annual event. So I was disheartened to read the email this week that Rebecca Blank, the incoming university president-elect at NU has stepped away from her role to face a battle with aggressive cancer. I wish her the best and trust that my alma mater will again find a top-notch academic to fill the role of university president.

The other notification has struck me more deeply. I missed the Tweet yesterday, spending a lovely afternoon on Lake Michigan, but this morning, the first news story I read was about WXRT radio guy Lin Brehmer. He too is stepping away for a while, taking a sabbatical from his role as the midday jock on my favorite radio station to begin chemotherapy for metastatic prostate cancer.

While I must concede that Rebecca Blank is just a name to me, Lin Brehmer has been a daily voice in my life for years. I would time my morning commute to be sure I was in the lab for “Three for Free,” the on-air trivia game orchestrated by Lin and Mary Dixon. A double-digit number of wins soothed my ego still bruised over long ago losses on Jeopardy! and It’s Academic.

And thanks to social media I am one of the thousands of listeners who have a bit of a relationship with Lin. He and I have Twitter bantered over Janet Jackson’s nomination to the Rock’n’Roll Hall of Fame, over an awful Guster song, and most recently over my allegation that the station program director required one Cure song per shift. “Just don’t play Friday I’m In Love on Fridays…”

As a pathologist specializing in the diagnosis of urologic diseases, I see about 5 cases of prostate cancer a day. While many, perhaps most, of those men do well, I still feel a sense of loss for each of those husbands, sons, and brothers whose prostate biopsy is under my microscope. I know their lives have changed. So it is for Lin. (No, he is not a patient of mine and I was not aware of his diagnosis or the previous treatment that he has revealed in his Tweet.)

Lin is always everyone’s best friend in the whole world. I know the wishes from all of those admirers are bringing him strength and leading to a successful outcome. I can’t wait to hear his voice on “XRT once more.

And just a final reminder to all of you. Men, ask your primary care physician to check your PSA level. Ladies, remind the men in your life. Just do it.

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The above is the opinion of the author and not UroPartners LLC.

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A Prostate Pathologist Pencil Pusher. Making a Better Diagnosis.

Using a pencil in the laboratory? Absolutely verboten. If you write down something in the lab, make sure it’s in indelible ink, magic marker, or perhaps blood. Something, anything, that can’t be erased.

Does a tech need to make a change in what they see on an instrument printout? Our accreditation regulations (courtesy of the College of American Pathologists) are pretty strict:

Original (erroneous) entries must be visible (ie, erasures and correction fluid or tape are unacceptable) or accessible (eg, audit trail for electronic records).
Corrected data, including the identity of the person changing the record and when the record was changed, must be accessible to audit.

In layman’s terms, that means carefully drawing a line through your mistake, initialing, and then dating your correction.

So what am I doing wearing pencil after pencil down to its nub? I am making sure I am the best pathologist I can be.

Through this part of my career, looking at multitudes of prostate biopsies, I have developed, inaugurated, and continuously improved a printed, unofficial worksheet that I use for every prostate case. At the top of each sheet our laboratory information system prints the patient’s name, age, medical record number, and pathology case number. I then search the medical record and add in relevant clinical history, such as previous biopsy findings, PSA values, and results from imaging studies.

The sheet then contains a row for every biopsy location. After looking at each slide I can quickly pencil in whether I think the biopsy is benign or malignant, what the Gleason Grade is, the extent of tumor, and any special studies I want to perform. It is really a very efficient way for me to work.

And I do it in pencil. Why? Because diagnostic pathology is not all ink–it is an art as well as a science. Cancer cells don’t actually have a big “C” on them under the microscope. Malignant changes can be striking, but they can also be subtle, and first impressions can sometimes be misleading.

Sometimes looking at the 7th core in a patient’s biopsy series can affect how I view what I saw on the 3rd biopsy. Sometimes special stains are going to nudge me to call a biopsy malignant that I had originally noodled in as “atypical.” Sometimes viewing a core the next morning will clarify my thinking, or a word from my associates will lead me in a better direction. When any of those things happen I grab my worksheet and out comes my pencil, eraser end first. And I mark down my new, improved, diagnosis.

Eventually, the worksheets get turned into our administrative team, entered into a digital pathology report, and following my electronic signature, become very official. Corrections can still be made, but only through a very regimented procedure, with documentation of every step. No more pencils, no more erasers.

But rest assured, the next morning I will be at the sharpener, getting my favorite diagnostic tool ready for another busy day.

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We Save Lives (and I Apologize)

Words have an impact. Whether the speaker is a politician, an entertainer, or a blogger, they must think about the words they choose–and choose carefully. I try to do that, but despite my scrupulous care, I made a blunder in my word choices in a previous blog and I want to apologize for it.

You may recall my last posting conveyed some thoughts on my profession, ranging from Sherlock Holmes to surgeon’s “fingerprints. And in a section dealing with statistics, I said “Some days every prostate I look at will be malignant and I feel like Dr. Death.”

I really should have known better. Within a few hours of posting, I received the following from Marty, a friend, and prostate cancer warrior:

What?

No, no. Better to realize you are giving these men (myself included!) a 2nd chance at life as they and their doctors learn that they now need to enter the “treatment phase” of their now discovered prostate cancer.
And B’ruch HaShem may that treatment extend their lives for many productive years to come!

We MUST stay positive.

Marty was so right. The diagnosis of prostate cancer is absolutely not a death sentence. By far, most men diagnosed with prostatic cancer will live long and fruitful lives, enjoying careers, family, and free time.

So instead of referring to myself as Dr. Death, I should have chosen an honorific like Dr. Decision Tree (I know, I know, it doesn’t have much zing.) My diagnosis is a key piece of the data set that guides the patient and his medical team as to whether to treat (surgery, radiation, hormonal modulation, immunotherapy) or not to treat (active surveillance) the patient’s cancer.

(And while we are talking about prostate cancer, here is my annual plug for PSA testing. Ask your physician if it is right for you and the men in your life.)

Marty, you have improved my mindset. I will watch my words with the focus of a laser beam. You reminded me that, as one of my previous partners used to say, “We are pathologists. We save lives!”

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Pearls for the People From a Prostate Pathologist

A tray of prostate biopsy slides is ready for microscopic review.

As my career in pathology heads toward the home stretch, some pearls I have picked up along the way, particularly during the last 17 years as a prostate pathologist.

I Can Name That Surgeon in 3 Cores

You all know that no two people have the same exact fingerprints or DNA. I can tell you that no two surgeons send the same exact prostate biopsies.

I can look at a case and know right away who the urologist is. Fourteen cores? That tells me this case is from Dr. B. A ten-pack? Got to be Dr. M. Lots and lots of cores from every location in the prostate? Dr. Y must be the urologist of the day. Long, thick cores come from Doc A, while Doc B sends more fragmented specimens. Sixty different urologists, sixty different biopsy “fingerprints.”

It’s Not Over Until the …

I sometimes get a bit exasperated looking at 15 or twenty prostate biopsy cores from a patient, all of which look perfectly normal; well-formed acini with lots of basal cells, bland stroma, nice even spacing.

But today I got a reminder why I need to look carefully at each and every one of those cores, all the way to the end. In two consecutive cases, I found nothing, nothing, nothing, until the final core in each case demonstrated prostate cancer. And not the potentially insignificant Gleason 3+3 kind, but high-grade cancers that will require treatment to preserve the patient’s health and hopefully prevent a cancer death. It’s humbling to realize that the 12th biopsy found what the first 11 didn’t.

Statistically, Things Tend To Return To The Mean

There is a saying in baseball that a ballplayer’s batting average is going to match the numbers on the back of his baseball card. A .250 hitter might go on a hot streak, but eventually, he is going to go back to being a .250 hitter.

It’s like that in the lab, too. Some days every prostate I look at will be malignant and I feel like Dr. Death. Other times, every case is benign, and while that is great for the patients, I worry that I am missing things, that I have forgotten what prostate cancer looks like under the microscope. But over time, it all evens out. From month to month, the percentage of cases I diagnose as cancer is the same. The diagnostic peaks and valleys cancel each other out. Statistics just don’t lie.

Whatever Remains…

Sherlock Holmes once said, “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.” Over a long career, I have realized that a pathologist’s most valuable skill is recognizing the many faces of non-cancer. While scanning prostate tissue, my brain automatically eliminates the benign, the inflamed, the reactive.

Whatever remains is where my concentration needs to be focused. Those areas might not be malignant, but I need to look at them carefully to make sure they aren’t. When in doubt, a second look the next morning, or a special stain, or a consultation with my colleagues will guide me to the truth. The Holmesian method of diagnostics.

I am sure I have learned a few other things, but I will save them for another snowy day.

This blog is the opinion of the author and not UroPartners LLC.

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Am I A Prostate Guru? Someone Thinks I Am!

As a 12-year-old camper in the summer of 1968, I was my cabin’s nominee for the title of Guru of Camp Chi, 3rd Session. I ran a strong campaign, with a catchy jingle based on “Strawberry Fields Forever.” Sadly I lost in a heated battle with a candidate from another cabin. As was customary way back then, I graciously conceded the election to my opponent, without asking for a vote recount. However, I never returned to Camp Chi.

I haven’t thought about being a Guru in the 53 years since then. People who weren’t alive in the 1960s may ask “What is a guru?” Webster’s has several definitions for the word, including “a personal religious teacher and spiritual guide in Hinduism,” and “a person with knowledge or expertise.” Definitely an honorable thing to be. So I was quite surprised (and quite pleased) to have that appellation given to me the other morning.

Dr. M, one of our more senior urologists had stopped by to introduce his young new associate to the corporate and laboratory team at our facility. I gave the two physicians my standard lab tour, one that I have been giving to new employees of our group for years–a little lab history, a bit of explanation of our lab processes, and some back-patting of our staff. Fifteen minutes of time, and a chance to put a nice shine on the lab’s place in the corporate hierarchy.

As the tour moved from histology to chemistry, from cytology/FISH to our new molecular studies lab, Dr. M became more and more effusive about how excellent the lab was, and how we were the glue that held the group together. I was certainly smiling behind my mask.

And then came Dr. M’s final pronouncement. “Les is the Guru of Chicago prostate pathologists.”

OK, Chicago prostate pathologists are not the biggest set of which to be Guru. The network of Chicago area pathologists who do mostly urologic pathology isn’t enormous. But between all the university medical centers, the giant private hospital systems, and a few big commercial labs in the area, there are a lot of great pathologists and lots of prostate biopsies being analyzed. But yes, I probably see more prostate biopsies than anyone else in the metro areas — 18,000 prostate cases seen under my microscope over the last 15 years would be my best guess.

But I think Dr. M’s comment about “Guruness” was meant as more than just a comment on the number of cases I have seen through the years. I hope he was summing up that along with my associates, I have helped our large urology group provide sterling health care to our patients throughout Chicagoland. That is certainly our goal, and it’s good to know the lab is appreciated.

And after more than 50 years, I am proud to say I am finally a Guru. But I still don’t think I am ever going back to Camp Chi!

The opinions above are those of the author and not necessarily UroPartners LLC.

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Every Paper Clip Is Another Life Changed

A small cylindrical plastic container sits on the desk behind me. I am not sure what it originally contained but now it is filled with paper clips. A quick glance tells me it must have a couple of hundred clips inside it, and every day I add a few more. I empty the receptacle a few times a year, but in the meantime, each clip tells me that someone’s life has been changed.

How is that so?

Medicine is more and more digital these days. You complain to your friends about how your internist spends more time typing into their laptop than they do talking to you. Your prescriptions go out to the pharmacy electronically, and reminders about your next appointment zip to your cellphone, instead of coming on a little postcard in the mail.

Here in the lab, we are digital too…but we still use a lot of paper. While most of the blood tests we do are managed without anything written down (each analyzer “talks” directly to the interface that sends results to our docs), we handle our biopsies quite differently.

Our Laboratory Information System (fancy name for lab computer) contains all the necessary information about patient age, and gender, and the site from which a bladder or prostate biopsy has been taken. But when I am looking at cases from 15 or 20 different patients, it really helps to have this data printed out. Also, I like to create paper worksheets for my prostate cases on which I can mark my findings for each of the dozen or so cores from each patient.

When my final diagnosis for the case is benign prostate, I can enter my findings from the worksheet directly into the LIS myself with a few keystrokes, and then add my electronic signature. No extra trees need to be cut for those cases.

But for patients in whom I find cancer, I turn my completed worksheet over to our administrative team. They keyboard the complex findings into the LIS and then print a copy of exactly how my report will appear to the clinicians.

When those printed cancer case reports come back to me, I review the information, correct the rare typos, have one of my colleagues concur on the malignant diagnosis, and affix my electronic signature in the LIS. The report can fly off to one of our urologists through an electronic labyrinth.

But because I need to select the appropriate charge to the patient for the laboratory and pathologist services, the reports are paper clipped to a billing slip. When I separate the report from the billing slip I toss the paper clip into the little container behind me. The container fills, each added clip representing another person given the diagnosis they were dreading and hoping to avoid.

Making those diagnoses is a pretty awesome burden and at times a humbling experience. I just hope that I can be as consistent as a bucket-full of paper clips; doing my job, holding it together, and remembering that there are people whose lives may be altered by every one of those diagnoses. They all deserve the best that I can be.

The above is the opinion of the author and not UroPartners LLC.

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Prostate Cancer Doesn’t Stop

Microscopic image of invasive prostate cancer.

Another telephone call. Another new diagnosis of prostate cancer. I see so many cases of prostate cancer each day, but some are more personal to me than others.

This time the worried young man on the phone is a friend, and he is indeed young. Carefully followed because his father is a prostate cancer warrior (survivor) his diagnosis has been made before his 40th birthday. He will benefit from all the advances in diagnostic techniques, prognostic methods, and therapeutics that have been developed in the last decade or so. Testing of the abnormal genetic material in his tumor, as well as his “germline” genetics (the genes he was born with) may assist in some decisions, as well as serve as a guide to family members about their own potential risk for prostate and other cancers.

Something else that will be available to him as he begins his prostate cancer journey is the presence of information seminars and support groups sponsored by UsToo, an international organization based in Rosemont. (Full Disclosure: I am on the Board of Directors of UsToo.) These resources bring prostate cancer patients updates on the latest in medical, surgical, and radiologic advances, as well as the ability to discuss with peers what to expect and how to deal with the life changes that the diagnosis and treatment may bring.

One month from today, on September 26th, UsToo along with UroPartners (More Full Disclosure: I provide pathology services to UroPartners) will be sponsoring the SEABlue Race/Walk in Lincoln Park, to raise funds for Support, Education, and Advocacy related to prostate cancer. I would love to invite you to join in on a fun-filled morning by the lake, but with no knowledge of what COVID restrictions we might be dealing with in a month, I will instead ask you to support me in my personal fundraising campaign. You can donate (any amount is welcome) by clicking here. Donate in honor of all the men you know–those who have prostate cancer, those who have lost a battle to prostate cancer, and those who just by being a male are at risk.

To my young friend–keep your hopes high and know that there are many resources to help you. Your dad is a success story, you can be too!

Just one note in closing. UsToo is merging with Zero-The End of Prostate Cancer in an effort to combine the strengths of each of these two great non-profits. You can learn more about the merger here.

Thank you for being a supporter.

Once more, the link to donate to my fundraising is Ustoo.rallybound.org/sea-blue-2021/lesraff

The opinions expressed above are the opinions of the author and not necessarily UsToo or UroPartners.

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“Friends” Don’t Let Friends Skip Their Prostate-Specific Antigen (PSA) Test

There has been plenty of talk about the reunion of the Friends cast earlier this month. Maybe you were a fan of the show during its original run and wanted to see how the actors had aged, or maybe you discovered it online and wanted to see something new. In any case, it was good to see your friends hale and hearty.

But then news broke this week that James Michael Tyler has advanced (Stage 4) prostate cancer. You may remember that Mr. Tyler played Gunther, the Central Perk manager who appeared in more episodes of Friends than anyone other than the Big Six. Call him The Magnificent Seventh.

So as I do anytime the chance arises, I remind you, or your partner, or your father, brother, uncle, our second-cousin-twice-removed to please get screened for prostate cancer (PCa). PCa is by far the most common cancer diagnosed in men in the USA, and the second leading cause of male cancer death.

The Prostate Specific Antigen blood test is still the most common test used in prostate cancer screening. It isn’t perfect, there are false positives and false negatives, but it is inexpensive, readily available, and when used intelligently to guide the patient-physician relationship it is useful in alerting to the possibility of prostate cancer. And there are lots of other associated lab tests such as Free PSA and Prostate Health Index (PHI) that can help make blood testing more specific.

Suppose you and your doctor decide a diagnostic biopsy is needed. There are techniques now that greatly reduce post-biopsy infection, once the biggest risk of the biopsy procedure. MRI studies can increase accuracy by pointing out suspicious areas to sample. And pathologists are great at making the correct diagnosis.

And if you wind up told you have prostate cancer? Treatment options abound – including no treatment in certain situations. And as in other cancers, the ability to test your DNA for abnormalities in both your cancer cells and in your non-cancer cells have lead to new treatment paradigms as well as assessment of the risk of prostate cancer in other family members.

If you are Black, your risk for prostate cancer death is even higher. US Too, the Chicago-based organization fighting prostate cancer (I am on the Board of Directors) has launched The Black Men’s Prostate Cancer Initiative. Check it out.

To all my friends with prostate cancer (and there are many) keep fighting the good fight. To the rest of you, black, white, or brown, with a family history of prostate cancer or without one, get screened.

Mr. Tyler, thank you for this opportunity for me to speak out once again. I wish you the best, and know that you have lots and lots of Friends!

The above is the opinion of the author and not necessarily UroPartners LLC or US Too.

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Another PSA for P.S.A.

I had a great time this past weekend. My high school buddies and I took our 16th annual baseball road trip. This year it was Philadelphia’s turn to survive our onslaught. The Liberty Bell, Independence Hall, miniature golf, batting cages, colonial outfits, and Philly Cheesesteaks were all on the menu, though I gave the last of those a pass. And it wouldn’t be a baseball trip if we didn’t spend one beautiful summer night watching the White Sox as they fell one run short to the Phillies.
Conversations followed the usual pattern. High school tales, some of which might be partially true, told and retold. “Top This” trivia contests about esoteric ballplayers from the 1960s and singers from the 1950s–yes “Seattle” WAS sung by Perry Como! Even a round of “Is this good for the Jews?” We discussed wives, kids, and grandkids and I was given tips on how to write without getting sued (the trip always has lawyers to the left of me, attorneys to the right.) We had a signature moment as one of our crew got stuck in the minivan, and almost a WWE type battle over who recorded “Haunted House” first, Gene Simmons or Sam the Sham.

Yeah, we had a blast. But through it all, I was the Debbie Downer. Someone mentioned 1960s TV star Bill Bixby and my comment was “He died of prostate cancer, get your PSA checked.” Listening to Warren Zevon’s “Werewolves of London, “He died of prostate cancer, get your PSA checked.”(note added 8/7/19–My mistake. Warren Zevon died of mesothelioma) Seeing a poster for the Rock and Roll Hall of Fame, “Frank Zappa. He died of prostate cancer, get your PSA checked.”

Too many of my friends and neighbors have been diagnosed, are being observed, or are being treated. I haven’t lost anyone close to me to prostate cancer since my dad passed away more than 25 years ago, but I know the terrible potential. And a ginormous new research study from Europe has confirmed that the PSA screening blood test for men SAVES LIVES. Early diagnosis works.

So to all my contemporaries, get tested. Even having the test performed just once has value. Ladies, tell your husbands, tell your brothers. Don’t let anyone dissuade you. Make it part of your annual physical. It matters.

I’ll be running in the SEA Blue Annual Prostate Run dedicated to Support, Advocacy, and Education for prostate cancer. To find out more and pledge your support visit the SEABlue website. All of you can–all of you must– help keep the men in your lives healthy.

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Did a Vegetarian Diet Cure a Prostate Cancer? I Need More Evidence.

prostate-cancer-low-and-high-grade — Microscopic appearance of less (left) and more (right) prostate cancer.

“I went on a vegetarian diet and my prostate cancer is gone!”

That was the Facebook post in a prostate cancer support group I occasionally follow. My immediate thought? Sorry, but I disagree with you. Based on the evidence you posted with that click-baity headline, I don’t think there has been a miracle cure. You posted pictures of a lab order with a diagnosis of prostate cancer. And you followed up with a picture of a pathology report (something I know a bit about) of a set of prostate biopsies from 15 months later indicating no malignancy was found. I am happy for you, I really am, but it doesn’t mean your eating habits have cured you, or that going on a vegan diet will cure other people.

A bit of background on prostate cancer. Back in the “good old days” prostate cancer was diagnosed by your internist with a good old rectal exam, or when you were being evaluated for symptoms such as an abnormal bone fracture. Most likely those were aggressive cancers, with growth often stimulated by the male hormone testosterone. Treatment consisted of surgery, or radiation, or using medicine to block the testosterone effect, or surgical removal of the source of that hormone — yes, you know what that means.

Since the advent of the PSA (prostate-specific antigen) blood test era in the 1990s (I am a believer) more prostate confined, less aggressive tumors are being identified. And based on the patient’s age, medical status, and some “under the microscope” considerations, many men with these tumors are being offered active surveillance – no current treatment, but regular PSA check-ups and repeat biopsies every year or two. If repeat biopsies show a more angry looking tumor, treatment can be considered.

And if the repeat biopsies are negative? Does that mean cure? Nope. Prostate biopsies sample only a small fraction of the prostate gland. And repeat biopsies are never in exactly the same location as the previous biopsies. So a small tumor that was sampled on the first go-round might not be in the path of the biopsy needle 15 months later. It doesn’t mean the tumor has gone away, though the tumor most likely hasn’t significantly grown. Of course, that is great news for any patient, but it isn’t the same as a cure. Surveillance is still necessary.

Is your vegan diet good for you? Sure, there are health benefits. And perhaps removing meat from your diet has removed some factors that might stimulate tumor growth. So I would never tell you to give it up. But I believe that a vegan diet cures cancer as much as I believe another post I read on Facebook that day–the one that says a sixteen year old has invented a perfect test for cancer diagnosis. But that’s a story for another day!

The above is the opinion of the author and not UroPartners LLC.

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