Internal Medicine Of Southwest Florida Newsletter
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PSA Screening
Healthy Recipe
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PSA Screening Guidelines Questioned
Dr. Raymond Kordonowy MD
Weigh-in on how you feel about PSA screening in men.Go to our blog site to leave your comments.  
Issue: # 15

We are heading into spring and soon many of our patrons will be going north for the summer. For those folks that are in Fort Myers year round, the summer months are preferred for your comprehensive physical examination.  Please consider changing your "annual exam" to the summer months if this applies. You can click the following to make this schedule change request: service request .
This newsletter's feature article attempts to tackle a very controversial topic (controversial even among the physicians in our group).  Perhaps you can help us by responding to our blog and weighing in on this topic after you have read the article.  Remember that usually the underlined and special colored text in the newsletter takes you to links or other information.  If you scroll over the text and left click your mouse you will link to the additional content. This enhances your newsletter experience and provides more useful information.
Since cardiovascular disease remains the number one killer in the United States, I felt a reminder of vascular risk assessment was appropriate for this newsletter (February was heart disease awareness month).  This topic is discussed in the second article.  Finally, another heart (and brain) healthy recipe is featured in this newsletter. Admittedly, I can't reference the source for this recipe but I can assure you, my wife and I truly enjoy this dish.
PSA Guidelines Are Questioned
PSA- A Blood Test
The U.S. Preventive Services Latest Task Force Draft Statement Tells Physicians to Not Recommend a Screening PSA Blood Test In Men

Prostate Specific Antigen (PSA) is a blood test used to detect prostate cancer. Most physicians recommend this test be done in males age 50-80 years of age to assist in the detection, diagnosis and treatment of prostate cancer. Usually this is done in conjunction with a physical examination of the prostate.  Presently the titled recommendation is in a draft statement and therefore not formally accepted yet.  There is a time period for open discussion on this issue.  This draft statement followed the latest data on this topic which was published October of 2011.  The draft states:The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. This is a grade D recommendation . This "grade D recommendation" means that the overall scientific evidence indicates there is no clear benefit and that the harms associated with the screening outweigh the benefits.


Already there has been significant discussion among my colleagues as well as reviews and physician commentary   in our periodical publications.  The information is difficult to sort out and quite frankly I feel the draft statement offers the easiest and most concise information for all readers.  The upshot of all the studies done to date is that a man's lifetime risk of dying from prostate cancer is small (under 3 out of 100 men). The probability of being diagnosed with prostate cancer, on the other hand is almost 16 out of 100 men! This would explain why most men at their health review visit tell me they personally know several friends who carry the diagnosis and have undergone treatment for the cancer.  To put this mortality information into some perspective, nearly 60 out of 100 adult men in the US will die of cardiovascular disease.


In the majority of men studied, survival is not really altered by early detection or intervention. In the pool of articles reviewed one study of good quality found that prostate resection (prostatectomy) for localized prostate cancer decreased the risk for prostate cancer-specific mortality compared with watchful waiting through 13 years of follow-up.  You may click the following link to see one of the original teaching videos for one way of doing this procedure. You may have to download QuickTime to view this; the option to download that software is on the site. There were six out of one hundred more alive at the end of the study period in the men that had the surgery. The benefit was limited to men under 65 years of age.  One of the studies indicated that in men between the ages of 55-69 there is a measurable relative risk of survival benefit but it is small. In the study there would be 7 less deaths for every 10 thousand men treated. It took 9 years of follow-up to demonstrate this benefit and perhaps it will look stronger after more continued follow-up. Actually just before I sent this newsletter out, the 11 year follow-up data was reported in the New England Journal of Medicine (March 15, 2012) and an Editorial by Dr. Anthony B Miller MD concluded: "there has been little change in the apparent benefit of screening order to prevent one death from prostate cancer at 11 years of follow-up, 1055 men would need to be invited for screening and 37 cancers would need to be detected".


The evidence appears pretty clear that in men 75 or over, "screening" PSA's offer no survival benefit.  Additional information shows that in the US, 9 out of 10 men who are diagnosed with localized prostate cancer undergo treatment.  Adding even more to the confusion, data has shown that even in men with normal PSA's who undergo random prostate biopsies, prostate cancer will be detected in as many as one of four.  In autopsy data as many as 80% of men aged 80 and older will have biopsy proven prostate cancer (but die of other causes).


This information has led to a concept of "overdiagnosis" into the PSA screening conversation. Essentially, the concern brought out by these studies is that prostate cancer is overly diagnosed, and that getting treatment in men over 65 years does not translate to survival benefit. Because of these issues, screening recommendations need to be reviewed.


The task force draft recommendation definitely goes against current practice patterns (mine included).  We have all been following the idea that early detection of cancer will translate to easier/definitive treatment and thus improved survival. What we appear to be ignoring is that in the process of this early detection (and I have prided myself on diagnosing this condition in many "routine" physicals) we are putting men in the way of significant risks.  Risks include: bleeding, urine retention, impotence, pain, emotional stress, infection, rectal bleeding from radiation, hot flashes and weight gain from hormone blockade, and in the cases of prostate resection-- risk of preoperative death. All of the aforementioned risks are recognized and quantified in the task force statement.


Dogmatic policies on this topic will not be easy to change. Recently the task force recommendation has even been politicized by some physicians representing the Urology profession. Statements have been made that the task force is not the appropriate body to assist in such issues.  It is healthy for us to remain skeptical of going against our agreed upon policies but I must admit, this update and review does make it difficult for me to remain nonchalant about advising men to have a PSA on an annual basis. The European study that showed survival benefit in screening PSA tested every 2-7 years and used a slightly lower PSA level for recommending biopsy (3 or higher). This indicates that less frequent testing combined with a lower level for biopsy recommendation maintains the detection rate. Additionally, it appeared to improve survival (age 55-69 year group) but since lest testing is done, there would be less false positives. Less false positives would mean less procedures and potential complications. Cost of screening would also be significantly less with these guidelines. This information, in my opinion, is worth consideration.  I feel that certainly in men over 70 years of age who have prostate cancer found, a randomized trial looking at watchful waiting versus early treatment might enlighten us further. Additionally, I am hopeful that the upcoming field of genome analysis may provide further risk prediction information that could be applied in helping physicians and patients know who would benefit from treatment while allowing lower risk subjects to remain in a monitoring pattern of care.  I also suspect that depending upon the mortality curve as medicine and health advances, we may have to reconsider when we recommend against continuing PSA screening.


Physicians are human beings just as patients are. We all have anecdotal cases of early detection "cures" as well as cases of finding advanced disease "late in the game". Couple these biases with the concern of being sued/liable for failing to diagnose and the readers can imagine how difficult it will be to let all the scientific evidence "sink in".  This could possibly result in an actual change of clinical use of PSA screening. The present routine of annual blood tests for PSA is such a deeply ingrained health recommendation.  Dr Allen Bent MD and Richard Albin Ph.D. coauthored an opinion piece published in November JAMA and they summarized this issue as follows:


"These approaches to managing serial PSA levels reflect either a fundamental misunderstanding of - or an unwillingness to acknowledge- PSA's limitations as a marker for early prostate cancer".


Dr. Kordonowy would like to hear readers weigh-in/comment on this topic. As I indicated prior, the physicians are struggling with this information among ourselves.  Some of the professional debate involves our uncertainty as to the expectations of our male patients about prostate cancer screening.  Currently the USPSTF task force statement is in draft form and thus the recommendation isn't "official" as of this newsletters release.

Cholesterol and Heart Attack Risk
High Cholesterol
There is more to the story than just measured cholesterol

Over the past several decades the medical field has accumulated a tremendous amount of population data linking abnormal cholesterol results with premature heart disease. There are several nuances to risk assessment, but a fairly reliable tool that is being recommended by the National Cholesterol Education Program is to use the Framingham risk assessment. The tool is available as a written table and as a computer-based calculator. Additional risk tools include the Reynolds Risk Score/calculator which incorporates other risk such as family history and abnormal inflammatory biomarker data. It has been shown to better predict risk especially for women and patients with family histories of premature heart disease.


The Framingham project started in the 1940s and is based on population information from Framingham, Massachusetts . This ongoing project has been looking at the Framingham population and observed associated disease events. Numerous studies have been published over the years and continued to be conducted from the Framingham project. The NCEP guidelines recommend using the predicted information from the Framingham risk assessment tool to help decide which patients will benefit from using medication to lower their cardiovascular risk. The tool incorporates a persons age, HDL cholesterol, total cholesterol, blood pressure, smoking status and sex to predict a ten-year probability that a specific person will have a cardiovascular event. Based upon that probability, recommended target levels of cholesterol are to be achieved either through lifestyle changes, medication or both. One of the shortfalls of the Framingham model is that it does not include a family history of premature heart disease.


Measured cholesterol from the typical lab is really a secondary marker of what is wrong metabolically in persons with abnormal cholesterol and cardiovascular risk. Lipoproteins are how various fats and cholesterol molecules are transporting cholesterol for cell use and in recycling. Certain lipoprotein characteristics are much more highly associated with atherosclerosis (vascular disease) than other lipoprotein profiles. In the past several years commercially available testing for lipoprotein analysis has become available and is now usually covered by most payers. Additionally, even when not covered these tests are now much more affordable. Dr. Kordonowy is a recognized specialist in interpreting this type of testing (Board Certified Clinical Lipidologist). More physicians are also becoming familiar with this type of analysis.


Not all persons need this type of intense testing. Many times, however, hidden or additional risk can be evaluated from this type of lab analysis.  Dr. Kordonowy feels strongly that persons with a family history of premature heart attack or stroke can benefit from advanced lipid testing. Furthermore, such testing can be helpful when recommending and monitoring medication and diet changes to lower atherosclerosis risk. Monitoring in this way can help patients understand that treatment is warranted, particularly if they are having potential side effects to treatment medications. If side effects may be occurring, it will help the doctor and the patient in knowing the individualized detailed risk of a heart attack especially by incorporating the status of vascular inflammation results.  If the risk is lower than perceived then holding medication may be an alternative with ongoing monitoring as part of the plan.  Additionally, advanced testing is helping Dr. Kordonowy tailor therapy specific to the individual patient. Certain genetic testing and lipoprotein patterns predict that some patients benefit from medications that block absorption of cholesterol for instance. Also certain medications can alter the bad pattern LDL lipoproteins to a more favorable and functional status. There is no "one size fits all" treatment for cholesterol management, which is why these advance tests help doctors hand tailor treatment to individuals for better risk prevention. 


Besides cholesterol measurements, certain other testing can also provide additional information about heart attack risk. Lp (a) is a special lipoprotein that correlates consistently with increased heart attack rates. This lipoprotein can be specifically measured predicted risk can be assesed. Having elevated levels will prompt lower LDL cholesterol goals than the NCEP guidelines alone would recommend. There are currently commercially available certain genetic tests that also independently predicted increased risk for stroke and heart. This area of science (genetics) is likely to reveal more helpful testing assays in the future. Dr. Kordonowy does order and interpret some of these assays at the present time-in selected cases. There is a gene, for instance, known as Apo-E allele in which certain patterns predict increased risk and predicts better response to dietary restrictions and certain non-statin medications.  Again, this specific genetic test allows doctors to hand tailor therapy, and make it more effective for the individual.



A Delicious Recipe For March
Red Lentil Curry Soup


Dried Red Lentils


In 2007, I read an article (Science NewsSeptember 15th, 2007; Vol.172 #11) indicating that turmeric which contains curcumin and is found in curry may be protective for Alzheimer's disease.  This is based on basic science information and on population studies..  One of the chemicals found in turmeric root is felt to be the substance offering this protection.  This recipe is delicious and easy to make.  My wife and I enjoy it routinely. It is a bit of an involved recipe but once made, it stores easily and can be a nice lunch dish for the upcoming week's menu.




  • 2 cups red lentils
    Turmeric Photo From Wikipedia
  • 1 large onion, diced
  • 1 tablespoon vegetable oil
  • 2 tablespoons curry paste
  • 1 tablespoon curry powder
  • 1 teaspoon ground turmeric
  • 1 teaspoon ground cumin
  • 1 teaspoon chili powder
  • 1 teaspoon salt
  • 1 teaspoon white sugar
  • 1 teaspoon minced garlic
  • 1 teaspoon ginger root, minced
  • 1 (14.25 ounce) tomato puree 



1. Wash the lentils in cold water until water runs clear (to prevent the lentils from getting "scummy"). Put the lentils in a pot of water, cover and simmer covered until lentils are tender (add more water if necessary). 

2.  While lentils are cooking: In large skillet or sauce pan, caramelize the onions in vegetable oil.

3.  While the onions are cooking, combine the curry paste, curry powder, turmeric, cumin, chili powder, salt, sugar, garlic, and ginger in a mixing bowl.. Mix well. When the onions are cooked, add the curry mixture to the onions and cook over a high heat stirring constantly for 1-2 minutes.

4. Stir in the tomato puree and reduce heat, allow the curry base to simmer until the lentils are ready.

5. When the lentils are tender, drain them briefly (they should have absorbed most of the water but you don't want the curry soup to be too sloppy). Mix the base into the lentils and serve immediately.


Prep time 10 minutes, cook time, 30 minutes, ready to eat in 40 minutes.

We thank you for your patronage. If you have a topic you wish to have covered in a future article please let me know. Internal Medicine of Southwest Florida prides itself in providing excellent, efficient preventive and diagnostic expertise for adults age 16 and up.

Raymond Kordonowy MD
Internal Medicine Of Southwest Florida
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