Dr. Kevin Most: Medical Testing

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Doctor Kevin Most

We have talked numerous times about how a celebrity often brings a health concern to the forefront of our minds. Often this raises awareness and has a positive impact in the community, other times it may raise more questions than answers. Last week we heard about Ben Stiller and his fight against prostate cancer and Brad Pitt and Angelina Jolie splitting allowed the media to highlight her decision to minimize her chance at breast cancer with surgery. Both of these media individuals raised awareness of important causes but also raised many questions about how they got to the point they did.

For Ben Stiller, it was his announcement that he had been treated for prostate cancer while in his 40’s. This treatment was triggered by a blood test known as a PSA test. The PSA test has been in the news many times, over the past five years . The recommendation for who to test and when to test has been discussed and researched many times. Currently the test is recommended for individuals over the age of 50 with average risk and age 45 for those with higher risk (African Americans or those with a father brother or son diagnosed with prostate cancer) Anyone getting the PSA blood test should also have a discussion of the potential harms and benefits with the physician before the test is drawn.

So what is the controversy? Why did Stiller have the test? He was not 50 and was not in a high risk group. He told reporters he had a thoughtful internist who felt getting a baseline test at the age of 46 was a good idea. The physician had enough concern with the initial test to continue testing him every 6 months and noted the levels continued to rise he did a MRI that determined he needed surgery. He was found to have a mid range aggressive form of prostate cancer. He is now thought to be cancer free.

This highlights the need for awareness of prostate cancer as it is second only to skin cancer in diagnosis in men with cancer. Prostate cancer grows slowly and often with no signs or symptoms. It also highlights that we do not have a great test for this disease. The reason to not test those not at risk under 50 is the potential harm caused by a false positive test. PSA can be elevated by infection, by some medications and in some cases as simple as riding a bike, The other bad thing about using this as a cancer screening tool is that some medications can actually lower the PSA level, even in patients with Prostate CA. So a high number may cause undue stress and a low number may cause inappropriate confidence of wellness.

The results of these tests may push a physician to additional tests, to MRI’s to actual biopsies of the prostate. Each of these elevate the cost of care and the chance for other complications such as infection. Most men with elevated PSA’s do not have prostate cancer, only 25% of men who go on to have a biopsy due solely to an elevated PSA actually have prostate cancer.

So the take home message on this is, if you are under 50 and have concerns, talk to your doctor about when the best time to begin screening with the PSA blood test.

We do need a better test for this very common cancer that when caught early enough can result in a cure.

Last week we heard of the breakup of Brad and Angeline, this did allow reports to highlight that she had a prophylactic double mastectomy after having genetic testing that showed she had inherited the BRCA 1 gene from her mother. This genetic mutation is well linked to a greatly increased risk of breast and ovarian cancer. Ms Jolie decided to have not only the mastectomy but also have her ovaries removed to minimize that risk. Ms Jolie’s mother had passed away from Ovarian cancer. Her coming out in public with this raised awareness of this test being available and many women stepped up and got this test completed. One of the problems with this testing was many individuals who were not appropriate for testing still stepped forward to have it done. The studies have shown which patients actually should be considered for testing and it really is based on historical data of cancer in family members. Those needing testing are based on early age cancer in family members and some other testing. Women with concerns should ask their doctor about the test and their risk of the mutation.

As we noted with the PSA test, there are pro’s and con’s of testing and results. Those who are tested and have the mutation may live a full life without breast cancer and those who test negative may still get breast cancer. So like all tests it needs to be used appropriately. That being said, we will see more genetic testing opportunities soon. Having this information about your risk will increase awareness, will impact on monitoring and will allow us in many cases to identify diseases early, allowing for earlier treatment. The great thing about most testing is awareness of an issue, this allows individuals to become educated on the illness. It allows them to understand the symptoms, it makes the monitoring and surveillance partially owned by the patient. Instead of the doctor’s office calling the patient reminding them it is time for their test, the patient is calling the doctors office to schedule the test. Education about this can make an impact on patient compliance.

The somewhat controversial portion of this is that Ms Jolie took the most aggressive option for patients with this gene. Patients have other options with this mutation. We have drugs now that lower the chance of breast cancer, some physicians will suggest that as well as more frequent screening to identify cancer early. Others may recommend removal of the ovaries, esp in a patient who is no longer considering childbearing. Some patients however may decide to have the surgery that removes the tissues that they are at risk for cancer in.

Breast Cancer Blood Test

This week the early results of a fascinating study were released on detection of breast cancer. As we all know there have been advances in breast cancer screening, gone are the days of simple analog mammograms, these have been replaced with digital mammograms, Breast MRI, 3 D tomosynthesis screening. Each of these are imaging studies that are getting better with each modality on identifying tumors earlier as we know the earlier we find this cancer the better the treatment and outcomes. A study published this week in Nature have the exciting news that a blood test may available in the future that will detect breast cancer.

How would it work? Well to make it as simple as possible, we know that cancer cells multiply more rapidly than healthy cells, as they multiply they use they put off specific compounds called isotopes. This study has shown that there is a difference in the amount and type of isotopes released by cancer cells compared to healthy cells. The test was performed on cancer cells grown outside of the body and compared to healthy cells, showing there is a difference in the isotopes from the two types of cells. Knowing this they are working on devising a blood test that would look for the isotopes released by cancer cells. If they found these in the blood, they would know there are cancer cells present as healthy cells do not produce the isotopes found in cancer cell metabolism.

With tight sensitivity a simple blood test may be able to identify the presence of a tumor before it could be captured in imaging studies. The test would not say where the tumor is but it would identify that cancer is present. This unique thought has caught the attention of many and is now being looked at for other cancers as well. The impact of this would be huge, theoretically if specific and sensitive it could allow a woman to have blood tests as a screen and not need mammograms until the blood test was positive. It would also lead to very specific imaging as we would know there was cancer present, allowing us to catch the disease at its earliest state.

This is not available but this study is very encouraging that it may be possible soon. We will see studies soon taking this to the next level.