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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“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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Don’t Be Afraid to Call Your Pathologist. It Might Make Both of You Happy!

“Mr. Michaelis wants you to call him,” said KB, my administrative manager.

“Who is Mr. Michaelis?” I asked.

“He is a patient. He wants to talk to you about a report that…”

At this point, most pathologists complexion changes to a deathly pallor. Their heart starts sprinting, a line of sweat breaks out on their upper lip and tremors extend from their shoulders to their fingertips. Four years of residency, a couple of years in a fellowship, an office in a dark office at the end of a faded linoleum-lined corridor, all so that they will never hear the words “a patient wants to talk to you.” We have made ourselves the “doctor’s doctor,” not the patient’s doctor.

For the most part, it is a successful maneuver. There aren’t many patients, or families of patients, who think of calling the pathologist when they don’t understand a Surgical Pathology report, or need an explanation of a Prolaris® or Oncotype Dx® test on a malignant prostate biopsy.

And that is OK. As pathologists, we send our blood test results or biopsy report out to the treating physician, and they do the heavy lifting with the patient. It makes sense since usually those providers have the best handle on what is going on with their patients and can best fit the test results into the entire health picture. But these days, with the advent of the (much hated) Electronic Medical Record, we pathologists, way off down the hall, can get a pretty good idea of what is going on with a patient’s medical care.

I will let you in on a secret. Despite my being an otherwise typical, pocket-protector toting, smeared glasses wearing pathologist, I enjoy talking with patients. I don’t mind explaining what I have seen under the microscope or what a particular change in blood PSA levels means. I try to use understandable words and remain professional, even in the face of patients who are upset with their diagnosis (or their bill) and really just want to vent.

There is one thing I tell patients upfront that I will not do, and that is advise them on their therapy. There are many choices, the evidence-based recommendations change daily, or at least monthly, and the patient’s urologist is really the place to go for proper guidance. Therefore I lay low on that issue, though when asked “Doc, what would you do if it was YOUR prostate,” I might give an answer.

So I listened without shivering as KB told me what Mr. Michaelis was upset about. I did a quick check of his report and of the Electronic Medical Record, and recognized he had a very good question about a blood level value referenced in the biopsy report. I gave him a call, explained who I was, and told him we would issue a corrected report. We then chatted for a few minutes about about his medical condition – but not his best therapeutic choices – and chatted for even longer about the weather on a cloudless, sunny, spring afternoon.

And for a few minutes I felt like a “real” doctor again!

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

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Prostate Cancer: Peaking Behind the Pathologist Screen

OLYMPUS DIGITAL CAMERA — An aggressive prostate cancer.

In the past few days, two members of Chicago media, radio host Dave Fogel and newscaster Hosea Sanders have shared that they are undergoing prostate surgery for prostate cancer. In both cases the cancers were discovered when abnormal Prostate Specific Antigen (PSA ) blood test results were followed by their doctors finding cancer on subsequent prostate biopsies.

Should every man have PSA screening. There is no universal agreement on that sticky question. I believe that men from about 50 to 75 years of age benefit from testing and careful, rationale, evaluation of abnormal results. In men with strong family histories of prostate cancer the need is even greater and may begin at a younger age. And as pointed out by Mr. Sanders, this is especially true of African-American men.

Not every abnormal result requires a biopsy, but a value abnormally high for age group, or rising steadily from previous results, needs to be evaluated. Urologists are well trained in triaging and determining when a biopsy is needed. Doesn’t this mean some men have to endure the discomfort of a biopsy when in fact they don’t have cancer? Yes, but in our laboratory practice, and in similar ones around the country, about 50% of the men whose specimens we see do in fact have cancer.

Do all men with prostate cancer need treatment? No, prostate cancer is not aggressive in all men. A great deal of the decision whether to treat or not is based on the microscopic appearance of the tumor, usually summarized as a “Gleason Score.” And it is here that my pathology associates and I in the lab have our most pitched battles.

At our daily case review we examine on a video screen every cancer case that each of us have seen that day. Most cases are straight-forward, but applying the scoring criteria in other cases is like throwing spaghetti at the wall. Only some of it will stick. Though each of us is thoroughly trained in the “rules” for the different scores and have each examined thousands of biopsies, we also bring our subjective opinions, our natural inclinations and the whispers of our teachers and national experts. The questions we ask, “Are those glands merging or just squeezed together? Is that a glomeruloid pattern or just telescoping?” do not always have a concrete answer.

What do we do to reach a consensus? We probe, we quote books and articles, we pull out pictures, we pull out our hair. We have never reached delivering blows or cussing each other out (at least aloud), but we each work hard to support our position. On some occasions we seek input from the East Coast or West Coast gurus. The elusive answers may impact how the patient faces their future. And yes, though we are behind the scenes and we rarely meet the men in question, we think of them as our patients too. That way we know we are giving them all our best.

And just as a reminder:

Please
Screen
Annually

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