Discover more from The Active Surveillor
Yale urologic oncologist Michael Leapman covers PSA density in new column
And a welcome to new readers plus an update for existing subscribers
[Editor’s note: This month, TheActiveSurveillor.com inaugurates four columns from experts responding to questions about Active Surveillance (AS) and lower-risk prostate cancer. Our leadoff hitter is Dr. Michael Leapman, a urologic oncologist from Yale [Go Bulldogs/Handsome Dan]. Send your questions about AS and urology, radiology, pathology, and sexual health via email to mailto:firstname.lastname@example.org
[Keep the questions short and sweet. They should be of general interest. Sign with your real name, or just initials, tell me where you live, how long you‘ve been on AS, how it’s going for for you. Share a whimsical signature if you’re so inclined.]
Question: I hear a lot about PSA density or PSAD. I know you calculate it by dividing your prostate-specific antigen (PSA) by the volume of your prostate. But what does it do for me?
Lost in Flossmoor, Illinois.
Dr. Michael Leapman: PSA density is important. It’s pretty clear to me from the evidence that PSA density can help cut through a lot of the noise from prostate enlargement and other factors when deciding who to biopsy. It is not a perfect marker but the risks of having aggressive prostate cancer are considerably lower at the lower end of the PSA density spectrum (e.g. less than 0.10).
But we have to be somewhat wary of using just one variable to make the decision for biopsy or not. I have almost never recommended against a biopsy if other variables are concerning based on a favorable PSA density.
There are cancers that just happen to make less PSA but can still be aggressive. We need to look at the whole picture: What is the PSA level exactly? How big is the prostate, what is the PI-RADS from the MRI, patient age, preference/risk tolerance, family history, and what are any other risk factors?
Michael S. Leapman, MD, MHS. is an associate professor of urology and clinical program leader, the Prostate & Urologic Cancers Program, Yale Cancer Center, New Haven. He has a special interest in low-risk prostate cancer, Active Surveillance, nerve-sparing robotic prostatectomy, focal therapy, high-risk disease, molecular imaging, and PSMA PET scans. Send Dr. Leapman questions on Active SUrveillane at mailto:email@example.com
[Note: PSA density (PSAD) is a calculation performed at diagnosis and is the serum prostate specific antigen (PSA) level (ng/mL) divided by the volume of the prostate gland (mL), resulting in a value with the units, ng/mL PSA density has been used as a prognostication tool in helping decide between an active surveillance or an invasive approach when managing prostate carcinoma. The cut-off used most commonly is 0.15 or 0.20 ng/mL2. ]
“Mo” better in Movember?
Sprout a ‘stache and donate
By Howard Wolinsky
Movember is the mighty Australian charity that promotes men’s physical and mental health.
Movember celebrates November as men’s health month by asking men to sprout “mo’s,” or mustache, to raise awareness about men’s health issues.
Movember used to just fork over funds by the millions to the Prostate Cancer Foundation (PCF).
Movember has become a big proponent of Active Surveillance— not a pet project for PCF, which is happy to reach into your pocket but really is focused on advanced prostate cancer,
Over the past decade, Movember has given $50 million to the Prostate Cancer Foundation to fund research. So Movember may be able to bend ears at PCF.
Movember is changing. I participated in a group of AS patients last year from North America and Europe who worked with Movember on a consensus paper designed to guide their research efforts on AS. Can this drip down to the Foundation?
Why not donate to Movember and ask them to earmark funds for AS and push the agenda at PCF? Go to: https://us.movember.com/get-involved/donate
Send me your mustache photos: mailto:firstname.lastname@example.org and I’ll pull together a page of you displaying your ‘staches.
Welcome to new readers and an update for existing subscribers
By Howard Wolinsky
In the past few weeks, there has been a surge in new subscriptions to TheActiveSurveillor.com, including many physicians from the world of Active Surveillance (AS) for low-risk prostate cancer.
You’re in the “AS Army” now—nearly 1,100 strong.
I ought to provide some background about TheActiveSurveillor.com newsletter and about me.
My son was telling me two years ago about the increasingly popular Substack newsletter format. I started playing with it. About an hour later, I had created my first newsletter, which I posted in January 2022. My son you qualify as “an Army” once you hit 1,000 readers.
I try to share news and views of interest to patients with low-risk prostate cancer and their physicians. This has led me to cover controversies over whether Gleason 6 should be considered cancer, whether transperineal biopsies are safer than transrectal procedures, what to do to relieve emotional distress issues in anxious surveillance patients, and whether AI will replace radiologists in diagnosing prostate cancer.
My newsletter’s motto is “Saving Prostates Daily.” I know we—you’re part of the equation, too —are helping to do just that. The proportion of patients on AS in the U.S. has increased to 60% now from 6% when I was diagnosed in 2010. There’s a 90%-plus AS uptake in Michigan, comparable to Asr ates in Sweden and the United Kingdom.
A close friend suggested that I make this an expensive, exclusive private newsletter. I could make some serious bread that way.
Instead, I chose a more difficult path.
I know the information here would make a difference. I knew that part of the audience included men who couldn’t afford an expensive newsletter.
So payment is voluntary. I know many people think the information on the Web is free.
But in reality, AI hasn’t taken over this domain—not yet. Someone like me still has to put in the time and the blood, sweat ,and tears to get the work done.
In other words, I have overhead to pay for software, broadband service, and transcriptionists to unravel interviews I do with top docs. Plus, Substack, the publisher, Stripe the money collector, the IRS, and the Governor of Illinois all take a bite for any paid subscription, like more than 40%.
I also have lost opportunity costs. I turn down much better-paying gigs to spend time with you here. My choice. That’s the passion part of a passion project.
One reader asked why I run Substack subscription buttons. It’s so I can remind you that this is costing me and that I want to at least break even. (I am losing a couple thousand dollars a year on this shoestring operation). I also have extra expenses of attending grad school in public health at the University of Illinois Chicago (Go Flames) to up my writing, research, and advocacy games.
Thanks to all subscribers, paid or not. 140 of you pay for subscriptions. I am grafetful. But I need to grow that number to stay afloat.
It’s ambitious, but I hope I can persuade 40-60 or more of you to subscribe in the next two months to help me get into the black.
Immediately, I’ll reduce the subscription buttons.
I get some gratification from knowing this little newsletter punches above its weight.
I appreciate the supportive letters I get from patients and doctors alike. A little love goes a long way.
One top doc from Hopkins in Baltimore, commenting on my coverage of the Epstein affair, told me: “Thank you for all of your patient-centric advocacy and for an always well-researched bulletin.”
Mark Soloway, MD Chief, Urologic Oncology Memorial Physician Group Division of Urology near Miami, an early adopter of AS, wrote: “I have enjoyed reading your (Active Surveillor) emails and I am encouraging my legion of AS patients to go to the Active Surveillor.”
Thanks, Drs. Anonymous and Soloway.
I should tell you a bit about me. I am a rare career journalist. I have been on the medical beat since 1970 after receiving my M.S. in journalism with high honors from the University of Illinois, Urbana-Champaign. (Go Illini.) I mainly have covered the medical beat though I have done my time covering murders, city council meetings, and the usual.
In my day, I also covered sports with a medical twist—such as the Bulls’ Michael Jordan’s risky toe infection and dah Bears’ punky quarterback Jim McMahon and his nasty chewing tobacco habit.
As you may have guessed by now, Chicago has been my base of operations for many years. As The Butterfield Blues Band put it, “Born in Chicago.”
The character in the song was born in 1947, and his father advised him he had better get a gun. I was born in Chicago in 1947, the Chinese Year of the Pig—and I do love BBQ but I am a vegan now. My dad’s only advice was a question when he learned I decided to pursue a journalism career: “People are asking (meaning he was asking), why didn’t you go into advertising where all the money is?” Instead of living a pauper’s life as a journalist. Answer? I like it?
I was the medical writer/editor for the Chicago Sun-Times for 26 years. The paper nominated me twice for the Pulitzer Prize for investigative medical reporting, specifically for exposing ethical and financial scandals at the American Medical Association that resulted in the firing of three AMA CEOs and several other top executives.
Harvard Business School did a case study on my work, and I lectured there for five years. I co-authored the book, “The Serpent on the Staff: The Unhealthy Politics of the American Medical Association.” I have written four other books, including with my wife Judi, the best-seller “Healthcare Online For Dummies” in 2001. (We had a true flash of insight recommending that people try out this new thing called Google.)
The National Press Club has honored me for consumer writing. U.S. Justice Thurgood Marshall presented me with a writing award from the Bar Association of the 7th Federal District for exposing the abuse of patients in state mental health hospitals. The American Bar Association also recognized that work. The Associated Press Managing Editors, the Chicago Newspaper Guild’s Peter Lisagor Award (“the Chicago Pulitzers”), the Association of Health Care Journalists, the American Public Health Association, the American Heart Association, the Kidney Foundation, and many other groups have honored my work.
I was a Mike Wallace Fellow—yeah, Mike Wallace of “60 Minutes” fame—at the University of Michigan (Go Blue), where I studied the politics, economics, ethics, anthropology, and sociology of health care. My project was on “Nazi medicine.”
I taught medical writing for almost a decade to grad students at Medill School at Northwestern (Go Wildcats). Last year, I had a cancer writing fellowship at the National Cancer Institute/National Institutes of Health last year. (Does NCI have a team mascot?)
I also completed the University of Maryland, Baltimore (Go Terrapins) School of Pharmacy PATIENTS Professors Academy on patient-centered research. I have been involved in several studies as a patient-researcher, including the best-read article in the Journal of Clinical Oncology in 2022 on renaming Gleason 6 as a noncancer.
The Prostate Cancer Research Institute recently recognized me with their Harry Pinchot Award for Advocacy in an online ceremony during their annual meeting.
Apologies for the brags, but if I don’t tell you, who else will?
I got upfront and personal with the cancer world in 2010 when I was diagnosed with a single core of microscopic Gleason 6 (Grade Group 1) “cancer.” As a result, I started writing about my experiences as a cancer patient on Facebook, which resulted in friends sending their family and friends to me for advice on prostate cancer. This led to a column, “A Patient’s Journey” aimed at physicians in MedPage Today launched in 2016. (one of the Facebook lurkers was the founding editor of the medical news site.) It all led to my helping to co-found support groups aimed only at patients on AS, Active Surveillance Patients International and AnCan Foundation’s Virtual Support Group for Active Surveillance.
(BTW, my cancer was seen but once when I was diagnosed by a surgery-happy surgeon, I resisted treatment and have been on AS since December 2010—my self-proclaimed “pros mitzvah.”)
That’s my story. Please at least sign up for a free subscription to TheActiveSurveillor.com, and, if you can, please help me to keep the lights on.
Tick-tock, vote … polls are about to close.
By Howard Wolinsky
Can you weigh in on my survey on what otherwise healthy men should do about Active Surveillance once they reach their mid-70s?
I have had almost 140 responses, but I’m greedy and would like more by the time I close voting on November 3.
There’s still time to answer a couple of questions on AS and related topics: https://forms.gle/oFvfH3rPdgJmEbiQ7
Can we can get a dialogue going with the urologists and develop guidelines to help us decide what to do about AS in older men?
By Howard Wolinsky I mentioned in this space the other day that my prostate signs point to stability and most likely I’ll die from something else. In a way, I am lucky. I have learned to co-exist with my “cancer” on Active Surveillance (AS) without overwhelming emotional distress. Mine has not been an Anxious Surveillance.