Category Archives: Polls

What is proper etiquette for the newly diagnosed cancer patient/doctor relationship?

I received a phone call yesterday from a young man that was newly diagnosed with prostate cancer from the southeast.
He was interested in robotic surgery and had several questions.
He told me he found a local urologist who performs robotic surgery and asked me what kind of questions he could ask. He was turned off by his primary urologist who he felt, was not interested in speaking about robotics.
Among the questions he asked me was “Can I ask the robotic surgeon how many of these operations he has done?”
That got me to thinking about what are proper questions to ask and what are proper things a physician should do?
The specifics of my thoughts will be for prostate cancer, but the generalities can be diagnosed for many cancer, surgical, and other medial problems.
I personally perform about 6-10 consultations per week for newly diagnosed urologic cancer (mostly prostate, but also bladder and kidney, and less often adrenal and testis.)
What I usually tell patients is that they should feel free to ask anything. They can also interrupt me if they need to without worry while I am speaking.
I think the number of a certain procedure that someone performs is fair. I think how old they are is also fair. Board certification, how long they have been in private practice, and any question is OK to ask.
I recommend patients come in with their families and to take notes. Several patients have had recorders, which I personally do not like very much, but do let patients record our consultation if they choose.
I am open to discussing any therapy for their ailment. For example, for my newly diagnosed prostate cancer patients, we discuss watchful waiting, hormonal therapy, surgery (concentrating on open and robotic (touch on laparoscopic non-robotic); radiation (XRT, seeds, combination, and now cyberknife as a local hospital is advertising it); cryosurgery and HIFU (which is currently not approved by the FDA in the US).
I have had one experience I did not appreciate. I was helping my partner with a patient of his who had a few questions for me. The patient stood up and stepped into my personal space (about 6 inches from my face) and asked me a direct question while staring at me. He explained later he wanted to look into my eyes to see if he believed my answer, regarding whether I could perform his complicated surgery. I did answer questions for about 5 minutes after that.
Other than that, I do not recall being bothered by any question, and if I feel it is irrelevant, may choose not to answer a question, but am not insulted by it.
I also do not have a problem referring patients to different institutions or for different therapies than I can not provide. Our group has not performed an open prostatectomy in over 2 years, so if someone wants an open operation, I refer them to a few excellent open surgeons in our area.
My goal is to make the patient and his family feel as comfortable as possible and choose the therapy or surgeon that they feel most comfortable with. That being said I do, as most physicians do, recommend the therapy that I do best: robotic surgery for prostate cancer. I provide a secure email and ask patients to call or email me if they have any followup questions.
I also suggest second opinions as I believe it helps a patient have more than one opinion on their problem. I often give out the name of a radiation oncologist who I trust, but sometimes a medical oncologist if that would be beneficial.
I also give out the names of 2 robotic surgeons that I would go to if someone in my family had prostate cancer if asked.
I give patients the option of speaking to 2 patients of mine that are similar to them in age and preoperative medical condition. This allows them to speak to someone who had what I expect to be a similar experience. Having a 73 year old man speak to a 53 year old man will not help very much, but he should speak to someone who is in his 70s.
I would welcome input from other physicians and patients about their feelings on this topic, as I am sure my views are not the only views.
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Bloodless Prostate Cancer Surgery

I have heard the term Bloodless Surgery many times and am familiar with it. A google search will also give someone who may not be familiar with the term a better understanding of how it is used.

There are many things that can be done to help avoid blood transfusions such as minimizing blood draws, diluting the blood during surgery by giving extra fluids during surgery, and giving medicines to help replenish normal stores.

I personally do not like transfusing blood and feel that even giving a patient his own blood back, is not entirely without risk. There is a chance of bacterial infection and a small chance that the blood can be mixed up. A friend and former Chairman of Surgery at Saint Barnabas Medical Center recently wrote an informative newsletter about the disadvantages of blood transfusions:


Just as the physical universe is changing so too is the health care
universe.  I’m a great believer in the power of change; really the
acceptance of, and adaptation to, change. I remember a warning from my
days as a medical student.  Someone told me that as I traveled through a
life in medicine the questions would remain the same but the answers would
change. How true! Here are some questions that have had their answers
revised in light of better understanding.


After a major operation a patient’s hemoglobin is stable at 7.5 Gms. The
patient did not receive any blood during surgery.  Should the patient
receive 2 units of red cells now or not?  Old answer: Give 2 units of
packed red cells now. New answer: Do not transfuse if patient is stable.
Transfusions have many potential complications including an increased risk
for post operative infection. Another question: A patient is scheduled to
come in for an open radical prostatectomy.  Should he put one or two units
of his own blood in the bank in case he needs to be transfused?  Old
answer: Yes.  New answer: No. Blood loses 2,3, DPG and red cells deform
during storage  even for a week or two.  The best place for his blood is
in his veins.    In cardiac surgery risk adjusted morbidity, mortality and
length of stay are all closely correlated with the age of the blood
transfused.

So all this sounds like I am in favor of bloodless surgery, which I am to an extent.
I have several issues. Any surgery which involves any incision has the potential to lose blood.

There is no such thing as bloodless surgery in the sense that blood will not be lost.
It is safe to lose blood and I think the term should be transfusion-less surgery as a more accurate, but maybe less marketable term.

The other issue is what I feel is my responsibility to inform the patient about what is likely to happen and what can potentially happen. My team at Beth Israel had an abstract presented at a national meeting earlier this year which concluded that we no longer had blood available for transfusion in the operating room. This was after 52 robotic prostatectomies. We are now past 150 robotic prostatectomies and have still not transfused a patient.

I still inform patients that a transfusion is possible, and other than several jehovah witnesses that I have operated on, I ask everyone to sign a blood consent. I am sure there will be a day when I feel one of my patients will need a blood transfusion and since the risks of receiving blood would be much less than the risks of the anemia they would have at the time which could lead to heart attacks and life threatening events, I would give the transfusion.

In conclusion, I tell my patients that it has been transfusion-less so far, but there is a small chance that they may need blood. I tell them I wouldn’t advise donating their own blood since the counts they start with would likely be a little lower and it is uncomfortable and likely it will not be needed. If they still want to donate blood, I will be happy to help them arrange to have this done.
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Genetics and inherited prostate cancer risk

Prostate Cancer: Major Genetic Risk Factor Found: “Harvard Medical School researchers have identified a DNA segment on chromosome 8 that is a major risk factor for prostate cancer, especially in African American men. The paper appears in the August electronic edition of the Proceedings of the National Academy of Sciences (also see PNAS’s
news tip below).

‘This paper identifies a genetic risk factor that about
doubles the likelihood of prostate cancer in younger African American
men,’ says principal investigator David Reich, PhD, Harvard Medical School
assistant professor of genetics with the HMS Department of Genetics and
the Broad Institute. ‘This finding may explain why younger African
Americans have an increased risk for prostate cancer than do other
populations–and may also explain why this increased risk in African
Americans attenuates with older age.'”

Source:
Medical
News Today

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I have prostate cancer: Do I have to wait 6 weeks to have my surgery?

One point that is debated among urologists is the time a patient has to wait between a prostate biopsy and surgery. While I was at Indiana my chairman taught me that time didn’t matter. The changes after a biopsy should not affect surgery after several days.
I took this with me to New Jersey and routinely perform robotic prostatetectomy within 6 weeks of biopsy. I havent had any problems with this and I have done surgery as soon as 2 weeks after biopsy. I would appreciate urologist or patient comments on this topic.
Evidence based medicine affirms my position: Urologists and epidemiologists from the University of Iowa have studied this topic.

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Nerve sparing- When and how much?

Since Dr. Patrick Walsh described the nerve sparing techniques for radical prostatectomy, urologists have been trying to spare the nerves responsible for erections. There is a debate among urologists on who is a good candidate for nerve sparing. Id like to ask urologists their opinion. Please vote on the poll below and add a comment below if you have time.
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Can Prostate Cancer Be Prevented?

This is a frequently asked question by patients and physicians alike.
We know there are genetic risks for developing prostate cancer. For example, African American men are more likely to get prostate cancer and it is more often a more aggressive type.
There was a review by Dr. Eric Klein, of the Cleveland Clinic, that was one of the most read medscape articles last year. This review summarized the literature on medicines, vitamins, and other products that may lower the risk of prostate cancer.

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Telling someone they have prostate cancer

One of the most difficult things that a urologist has to do is to tell his patient that he has cancer. I recently had a somewhat heated debate with my partner in robotic surgery.
Prostate cancer is the leading solid organ cancer in men and is diagnosed by a biopsy in the office. The reasons for a biopsy are given by the urologist when scheduling the procedure and the urologist is present for the biopsy.
I have had discussions with my partners about the two main ways of doing this for prostate cancer and there is a difference in opinion. The two ways are over the phone or face to face.

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