Men's Health Issue - PSA

What is PSA? PSA stands for prostate specific antigen, which is a protein produced by both normal and cancerous cells of the prostate gland. It is used as a screening test for prostate cancer; although this is met with controversy. It is also used to assess response to the treatment of prostate cancer.

The PSA value increases with increasing age because the prostate gland size increases. As a result, the normal reference range may be appropriate based upon a man’s age. This may help understand what a true normal or abnormal number may be and help avoid needless biopsies in older men.

It is also known that different races have different PSA values; black men in particular tend to have higher PSA values than white men without cancer. As a result, there is discussion that the PSA value should be race dependent. This is still unclear, but you can see the issues surrounding PSA values.

It is interesting that the higher the BMI (obesity) the lower the PSA values tend to be. This may be due to higher plasma volume. If that is the case, consider the importance of the rectal exam (o joy!).

There are some medications that lower the PSA value (5-apha reductase inhibitors). When on such meds (i.e. finasteride) the PSA interpretation need be adjusted. Some say any increase in PSA value while on these meds need to be evaluated.

Other medications such as the cholesterol lowering statins (ex: Lipitor) also appear to be able to lower PSA values. So maybe a two-fer? Lower cholesterol AND lower PSA? It appears promising, if you like statins.

What are other causes for elevated values? There are several major causes of elevated PSA values: BPH (benign prostatic hypertrophy (enlarged prostate)); prostate cancer; inflammation and trauma.

Of these, BPH is the most common especially for men over 50 years old. Simply put, bigger prostates produce more enzymes. Unfortunately, it is not that simple, as bigger prostates may also have pockets of cancer as well. In addition, treatment of BPH may lower PSA values. What to do? Work closely with your doctor.

Prostatitis is another common cause. As a result many physicians will treat an elevated PSA value with antibiotics for presumed infection than repeat the PSA after four weeks or so. This approach is also controversial as to its effectiveness; it is however the usual practice.

In regard to trauma, vigorous bike riding may elevate the PSA value as can a digital rectal exam. Although not proven, the blood test probably should be checked before the exam or after a time of biking abstinence.

Other methods for screening prostate? There is something called PSA density that you may hear about to more accurately predict cancer if you have an elevated PSA value. This is the volume of prostate as measured by ultrasound. The density would be the PSA divided by the volume. This is also controversial as there are different standards regarding the measurements with the ultrasound.

The approach that has gotten the most traction is something called PSA velocity, or the rate of change of the PSA over time and not so much the actual value. This velocity seems more related to the risk of death from prostate cancer.

So, PSA is a valuable tool for prostate cancer but is not specific for cancer. The use of PSA velocity or density has not proven of great use. Thus, the number of biopsies done is still too high. The value of checking PSA seems higher the younger you are (starting age 40-50).

What about Glycemia - Hemoglobin A1c

It has been known since the 1970s that glucose (sugar) can attach to proteins in the blood. If the sugar in the blood is high enough for long enough then the attachment of the sugar to the protein becomes permanent.

The demonstration that the development of microscopic complications in patients with type I diabetes can be slowed by treating high sugars led to the pursuit of measuring blood glucose levels, thus the development of the A1c test. In other words, when high sugars in type 1 diabetics were treated it reduced complications from developing and thus the need for the A1c test to measure.

The most useful test for measuring this phenomenon is called glycosolated hemoglobin, or the HbA1c. Red blood cells readily attach sugar molecules. Just as in the above scenario, the amount of sugar and the permanency of the bond is proportionate to the amount of sugar present in the blood. Since red blood cells only survive 120 days in the blood, the A1c is a measure of the average blood glucose over that 120 day time frame.

There are now many studies and plenty of data supporting the correlation of the A1c to diabetes control. In fact, the measure of A1c is now the means by which to diagnose new onset diabetes.

There are, however, sources of potential error related to the A1c values. This test is influenced by red blood cell survival. If a person has iron deficiency anemia or B-12 or folic acid deficiency the result of the A1c may be falsely high.

If there is a hemolytic anemia( blood loss) causing the marrow to produce young blood cells the A1c value may be falsely low.

If there is a hemoglobin problem such as sickle cell disease or thalassemia the values may also be off( high). Other problems such as a chronic disease state such as kidney disease may also give false values. Other issues that affect the A1c test includes: if you are on dialysis, taking erythropoietin or possibly of Black or Hispanic descent.

If the scenario exists where the A1c values are high but the blood glucose levels are excellent, I advise checking the before meals sugar as well as two hour after meals sugar and adjust medications appropriately.

Let’s consider the issue of high blood glucose values after meals for a moment. Optimal treatment includes changes in either nutrition or insulin regimen. For example, a large meal containing a lot of quickly absorbed carbs and low in fiber may cause a large post meal hyperglycemia. Changing the meal, eating less with each meal, eating more in between meals, increasing the amount of soluble fibers should lower post-prandial sugar level. Otherwise, using more premeal insulin of the short acting variety may be of benefit.

The level of A1c to help prevent complications for type 11 diabetes is clear: 7 %. This is based upon a large study called The United Kingdom Prospective Diabetes Study. For older patients is especial, care must be taken to avoid low( hypo) sugar reactions! That being said, it is very clear sugar values are directly related to future complications i.e. a one percent fall in A1c was associated with a 35% reduction in microvascular disease.

So,  follow up with your doctor to check your A1c level every 3 months if you are diabetic!

http://www.medindia.net/patients/calculators/bloodsugar-HbA1c-convertor.asp

___________________________________________________

Dr. Frank Marinkovich owns and operates Eastside Family Health Center in Kirkland, WA. Serving Kirkland and the Eastside, Seattle, Bellevue, Renton and the surrounding local communities. Specializing in Primary Care, Automobile Accidents and FAA physicals. Visit them online at Eastside Family Health Center or call them at (425) 899-2525.
LIKE us at Facebook!
FOLLOW us on Twitter!

Obesity

As many are aware, obesity is a major issue in America and the problem is getting worse. More than 33% of Americans are obese ( defined as a BMI > 30 ). More than 64% of Americans are overweight (BMI>25).

It costs America approximately 100 billion dollars a year to treat obesity and the complications that arise from it. This is in addition to hidden costs, such as days missed from work and early death( less taxes).

There are several well documented health hazards with obesity, such as diabetes, heart disease, stroke, cancer, arthritis, liver disease, sleep apnea, and depression. The risks increase with the degree of obesity.

The most practical means of measuring obesity is the body mass index. This is calculated by dividing the weight in kilograms by the height in meters( kg/m).

BMI Categories :   25-29 overweight; 30-34 obese; 35-39 moderately obese; 40-49 severely obese; >50 super ( morbidly) obese.

Well, what to do? The hallmark solution will forever be diet and exercise, but for most people there has only been limited success and not for a lack of desire or effort. Surgery has come into medical community acceptance over the last several years due to studies showing the improvement in obesity complications.

Weight loss surgery (called bariatric from Greek word baros meaning weight) works by either malabsorption or restriction. Restriction procedures limit the amount of calorie intake by reducing the stomachs reservoir capacity or via creation of a blind stomach outlet. Gastric banding is a purely restrictive procedure. This limits solid food intake by restricting the stomach size as its only mechanism of action. The small intestine must then absorb nutrients. The weight loss with purely restrictive procedures is more gradual.

Malabsorptive procedures work by shortening the length of the small intestine. This is done by shortening of the small bowel or by diverting around it. Examples include jejunoileal bypass or duodenal switch operation. The weight loss can be huge, but the complications many such as protein loss or micronutrient deficiencies.

The famous Roux-en-y gastric bypass is both restrictive and malabsorptive. In this operation you are left with a small stomach pouch; however, the small bowel is rerouted favoring additional weight loss via dumping and mild malabsorption.

So, does surgery work? It does, especially for those with BMI >40. The mean weight loss percent of excess weight loss was 61%. Diabetes completely resolved in 77% and either improved or resolved in 84%. Also look at these results: high cholesterol improved 70%; high blood pressure improved 62%; sleep apnea resolved 86%; reflux improved as well as urinary incontinence. Because of these data, I am now a fan of weight loss surgery.

The amazing thing is that there is now data showing a decrease is overall mortality. The reduction of the complications of obesity reduces overall mortality by 29%. As always, if one can reduce BMI by diet and exercise this is the safest way. Otherwise talk to your doctor about weight loss surgery. There are several different types of surgery; an expert in the field will need be consulted.

Let’s review some of the indications for surgery intervention: Be motivated! Have a BMI>40. Or, have a BMI>35 with co-morbidities(other diseases or complications) such as diabetes, blood pressure, apnea, severe arthritis, heart condition etc. and having failed non-surgical programs.

The most common surgical technique is the laparoscopic gastric banding. The upper stomach is banded by a tight, adjustable soft silicone ring connected to an infusion port placed under the skin.

The port can be accessed with ease via a syringe and needle. The band is adjusted to deal with weight loss as well as nutritional issues. Data shows an expectation of about 40-75% weight loss at two years. But note! It is easier to cheat with the lap band! So, a comprehensive approach is needed as well as good motivation.

The decision to proceed with a surgery for obesity is a serious one as there are many potential complications. For this reason it is necessary to follow protocols.

We also have the BMI Calculator on our website. Check it out here: Eastside Family Health.

___________________________________________________

Dr. Frank Marinkovich owns and operates Eastside Family Health Center in Kirkland, WA. Serving Kirkland and the Eastside, Seattle, Bellevue, Renton and the surrounding local communities. Specializing in Primary Care, Automobile Accidents and FAA physicals. Visit them online at Eastside Family Health Center or call them at (425) 899-2525.

LIKE us at Facebook!
FOLLOW us on Twitter!