Ross Krasnow, MD

As the sixth most common cancer in the U.S., bladder cancer affects about 80,000 Americans each year. And because men are at higher risk than women, it’s the #4 cancer risk for them. Bladder cancer can grow and spread very quickly. The good news is that it is treatable—but like most cancers, the earlier it’s discovered, the more successful that treatment can be. The five-year survival rate for cancer that has not spread beyond the bladder is as high as 96 percent. But when that cancer begins to spread, that number can drop below 10 percent. So, it’s essential to understand potential risk factors, and to take action if you see any warning signs, particularly blood in the urine. Let’s first consider some risks for bladder cancer. Perhaps the most significant is smoking. Smokers are three times as likely as non-smokers to develop this disease. Age can also be a factor: Bladder cancer tends to appear after age 55, and the average age at onset is 75. Men have about a 30 percent greater chance of developing it than women, and white people are twice as likely to contract it as Blacks or Hispanics. A family history may also increase the risk, as well as the patient’s own prior history of bladder cancer, bladder infections, or repeated catheterizations. Certain medications and herbal supplements may add risk, including the diabetes medicine pioglitazone (Actos) and herbs in the aristolochia family, such as birthwort and snakeroot. Arsenic in drinking water, as well as some workplace chemicals—specifically aniline dye compounds—may also contribute. Our kidneys are continually at work, extracting waste products from the blood and excreting them in the form of urine. The bladder is the temporary holding tank, storing the urine until it’s expelled. Because the kidneys are very efficient at removing toxins from the blood, the resulting urine may contain elements that are potentially hazardous to the bladder. For example, in smokers, those elements are absorbed within the lungs and enter the bloodstream. The kidneys release some toxins via urine, which makes contact with the inner wall of the bladder. These toxins can potentially alter DNA and cause cancer. Bladder cancer can develop and grow quite aggressively, although in its early stages, it seldom causes pain. Blood in the urine is the most prevalent warning sign that something is amiss with the bladder, particularly for people over 50. If you see blood even once, schedule a visit with your doctor. In later stages of bladder cancer, the patient might experience an increase in urinary incontinence or frequency, a burning sensation, or a feeling that the bladder is not fully emptied. The feet and kidneys may also swell, and the patient may have back pain or bone pain. In order to determine the extent of bladder disease, I complete a full medical history with the patient and typically order a CT scan of the abdomen, with and without contrast. Occasionally, we conduct specific tests on the urine. We also schedule a cystoscopy to obtain a direct view of the inside of the patient’s bladder, using a tiny camera and lights mounted on a thin, flexible tube passed through the urethra. With this same scope, we are able to biopsy small samples of bladder tissue for lab analysis. The procedure, which typically takes about 30 minutes, can be done in the office with numbing anesthesia. Most of my patients do fine afterwards, with only minor irritation and more frequent urination, both of which go away quickly. If one or more tumors is found, surgical removal of the tumor tissue is typically the recommended approach. When disease is present only on the inner lining of the bladder, it can be removed endoscopically without incisions, via a procedure known as transurethral removal of bladder tumors, or TURBT. In most cases, these tumors are completely removed with small instruments passed into the bladder. TURBT surgery leaves the bladder and urinary function intact, and the patient has a very good chance of no recurrence. Although many cancers are visible to the trained eye under regular, white light, we frequently deploy blue light technology as well. We fill the bladder with a special dye, about an hour before surgery. Rapidly dividing cancer cells absorb the dye more quickly than healthy cells; under blue light, those abnormal cells glow pink. Blue light technology helps define the edge of the tumor and can sometimes reveal lesions too small to see under white light. It is particularly helpful in diagnosing cancer that may have returned following a traditional procedure. At MedStar Washington Hospital Center, we perform up to 10 blue light procedures per month—more than any other medical center in Washington, D.C., After a TURBT procedure, we can introduce any necessary chemotherapy or immunotherapy agents directly into the bladder, where they can do their work without impacting other parts of the body. If a tumor has invaded the walls and muscular structure of the bladder, we may need to remove the bladder completely, which calls for a plan for the storage and elimination of urine. Depending on each patient’s unique situation and preferences, we have a few options: The most common approach is to use a short section of small intestine to create an ileal conduit, a pathway for urine to exit the body through the abdomen, where it collects into a urostomy bag. My conduit patients do very well with the procedure and with adapting to life with the bag. Most of my patients are able to resume normal activities, including golf, tennis, and other forms of exercise. In a neobladder surgery, we create a new bladder from a longer segment of small intestine, which is grafted to the kidneys and urethra to function similarly to the original bladder. The patient must learn to use abdominal muscles to empty the new bladder, which has no muscle mass of its own. This surgery is more complex; however, in cases where we can perform it robotically, we reduce blood loss and risk of complications for the patient. Continent cutaneous diversion is a hybrid of the previous two options. We create a new bladder pouch from a portion of small intestine, with a pathway through the abdomen to the outside. The pouch remains inside the body but is not connected to the urethra. It is emptied periodically via a tube inserted into the new abdominal port. This procedure also eliminates the need for the urostomy bag. In the most serious instances, when cancer escapes the bladder and is found in other areas of the body, we use trimodal therapy, combining surgery, chemotherapy, and radiation. With today’s effective therapies, we are sometimes able to spare the bladder and help the patient maintain normal bathroom function. An exciting development is the current research on immune checkpoint inhibitor therapy. Cancer cells are very clever; they can cloak themselves with normal-looking proteins to hide from the body’s immune system—wolves in sheep’s clothing. But these new agents remove the disguise, allowing the immune system to spot and eliminate the cancer cells. When these therapies receive FDA approval, we expect them to be game-changers in the treatment of bladder cancer. MedStar Washington Hospital Center is one of just a few hospitals performing prostate capsule-sparing bladder cancer surgery. When bladder removal is required, the prostate has traditionally been removed along with it, impairing erectile function. But by means of this surgery, a portion of the prostate is left behind, significantly reducing that risk, as well as the chances of post-surgical leakage or urinary incontinence. Thanks to prostate capsule-sparing bladder surgery and neobladder surgery, we have the very real prospect of men surviving bladder cancer with sexual function intact and no need for a urostomy bag or absorbent pads or undergarments. This is a huge advance compared to just a decade ago—and particularly important for younger, sexually active patients. Our urologic oncologists team closely with the medical oncology and radiation oncology units to manage disease in our patients closely. Our physician assistants and nurse practitioners are specially trained to help surgery patients adapt to any new bathroom routines that may be required following their surgery. Bladder cancer is serious and it can spread aggressively. Tumors may bleed for a short time, then stop. So if you notice blood in your urine even once, be sure to schedule a visit with a medical professional. Delaying treatment for even a month may spell the difference between an early diagnosis with a very good prognosis and a more challenging outcome. It’s never a mistake to heed the warning and protect your health.

Testicular cancer is among the most treatable, curable cancers today—a disease that medical science has truly mastered. But it’s still a disease that the average guy prefers not to talk about, even though talking about it could save his life. Caught early, the odds of beating this cancer are greater than 99 percent. But untreated, it can turn deadly. That’s a powerful motivator to be aware of the potential risks. Here are five important things to keep in mind: Testicular cancer is a younger man’s disease—unusual for cancer but also a reason why it’s so treatable. It generally affects males between the ages of 15 and 44 who have little or no other medical problems; average age at diagnosis is 33.   When found, the cancer has generally remained localized, and responds very well to surgery, with a survival rate of 99 percent. Even in cases where it has spread, it responds well to chemotherapy, with a survival rate of 95 percent.   Although testicular cancer seems to strike randomly, a short list of risk factors can be at play; for example, at slightly higher risk are men whose dad or brother have been diagnosed, as well as men born with an undescended testicle. So far, we’ve seen no connection to other typical contributors to cancer, like diet, obesity, inactivity, tobacco, or other lifestyle factors.  Men whose testicular cancer is treated with chemotherapy or radiation have a slightly higher lifetime risk of other cancers, although this percentage is very small.  This cancer will affect about one in every 250 men, with about 9,500 American men diagnosed each year. While still fairly uncommon, it appears to be on the rise worldwide; we’ve also seen an increase in infertility at nearly the same rate.   There’s no clear data to explain either increase, but I would not be surprised if we eventually find a link to industrialization. Perhaps something in our environment disrupts normal metabolism in the reproductive system. But any evidence of that remains to be discovered. So, what are the signs of testicular cancer? It most commonly presents as a testicular mass—a lump you can feel on the surface of the testicle—which grows over time. Unlike more common cancers, there is no established screening protocol or routine imaging studies to find and diagnose such a mass. This is why I recommend that every guy get into the habit of self-examination, every month.  The lump may feel like a marble, harder and less compressible than surrounding tissue. It’s unlikely to cause any pain or discomfort. Most men discover it on their own and seek medical attention when they realize it’s getting larger. That’s the right thing to do. Most lumps and bumps are not cancerous, but let your doctor make that diagnosis. The majority of lumps we see have remained localized—totally encapsulated. However, left untreated, this disease can spread to other parts of the body, most commonly the lymph nodes in the back or abdomen, spurring symptoms such as:  Dull ache or soreness in the affected area  Back pain  Swollen glands in the neck   Shortness of breath   Anorexia or nausea leading to weight loss  Breast enlargement—very rarely, hormones from some tumors may cause this condition, known as gynecomastia  We don’t biopsy testicular tumors, as this type of cancer can spread very easily and biopsy increases that risk. Rather, the gold standard for confirming testicular cancer is ultrasound, which hardly ever returns a false positive.   If the ultrasound points to the presence of cancer, we proceed with surgical removal of the entire testicle. Although this measure sounds extreme, the procedure is not difficult and is extremely effective at treating the cancer.  Surgery to remove the cancerous tissue generally involves making a single small incision. For men who prefer it, we can simultaneously insert a prosthetic at the same time—a saline-filled silicone device, matched for size, that looks and feels like the original. The patient may also have the prosthetic placed at a later date, if desired. The tissue that we remove is sent to the lab, where we perform additional imaging studies to determine if the cancer has spread. Most of the time, it’s confined to the testicle and we simply conduct routine monitoring for another five years or so, to be safe. Post-surgery, most men do well with anti-inflammatory medication for minor discomfort and can resume their normal routine within a few days.  In the unlikely event that a patient’s cancer has spread to surrounding lymph nodes, this disease responds very well to chemotherapy and radiation, although we don’t always treat with both. Occasionally, more extensive surgery is required to remove diseased lymph nodes, but this is not typical.  It may seem like a big deal to have this particular part of the body removed. But the reality is, most patients have few, if any lingering effects. It doesn’t negatively impact sexual function, and most survivors still make enough sperm to begin or expand their family.   The exception may come in situations when the disease has spread—chemotherapy and radiation can damage sperm cells. Although the damaged sperm will clear with time, it’s best to postpone pregnancy plans for one year following treatment. Very occasionally, I may recommend banking sperm, in case sperm production is permanently affected. A urologist specializing in fertility can complete a full evaluation.  The lifetime risk of recurrence, or of developing other cancers, is very low. But it’s not zero, so I encourage all my patients to eat well, stay active to maintain healthy weight, limit alcohol intake, and quit smoking (tobacco increases the risk of many other diseases and may complicate treatment).  I recommend that every man perform a self–examination at least once a month. This can be done most effectively in the shower, when warm water relaxes the scrotum and makes it easier to feel for anything out of the ordinary. Simply grasp each testicle, one at a time, and roll it around in your fingers. You’re feeling for anything firmer than the surrounding tissue on the testicle itself.  Of course, it’s not unusual to discover something that raises a red flag, but turns out to be completely benign—for example:  Lumps can occur in the epididymis, a spongy structure behind the testicles where sperm mature before leaving the body. These lumps can include benign cysts such as a spermatocele, a collection of sperm that settles in one spot.  A varicocele is an enlarged blood vessel. A hydrocele is a buildup of fluid. Either one may feel strange during self-exam.  It’s not unusual to find vestigial bumps that are just a normal part of your anatomy. When you do the exam regularly, you’ll know what’s normal and can be on the lookout for anything new.  I’ve diagnosed all these situations in my practice and very few require treatment, unless they become symptomatic and irritating.    But if you find something, say something. Getting checked for nothing is far better than ignoring something critical.  MedStar Washington Hospital Center has a comprehensive program for the diagnosis and treatment of urological problems. We have all the resources needed, from advanced testing to the most skilled and highly trained surgeons and support professionals.   We take every precaution to prevent the spread of COVID-19, and we encourage you to check in with us whenever you notice a testicular issue, rather than potentially giving a disease like testicular cancer time to get worse.  

Prostate cancer is among the most common cancers in the United States, but also among the most survivable. Although it’s estimated that as many as 80 percent of men will develop it, most forms of the disease grow very slowly, are not problematic and are nonlethal. In fact, some men will never even know they have it. But, because this cancer can become deadly for approximately two percent of the male population, it’s important for every man to talk with his healthcare provider about it—especially since the early-stage disease shows no symptoms. Having that conversation is especially important for men in the District of Columbia, which has among the highest incidence of prostate cancer nationwide. This cancer affects about 138 men per 100,000 in the D.C. population. That’s higher than the national average of 104 per 100,000—and rivals the top four states of Delaware, Louisiana, Mississippi and New Jersey. We don’t have clear indicators for why men in these areas are at higher risk, but it’s likely demographic. Because African American men are at a greater risk in general for this cancer, we see higher instances in places with large African American populations. As part of the male reproductive system, its main job is to secrete fluids that help transport sperm during ejaculation. A healthy prostate is about the size of a walnut and completely surrounds the urethra, the tube that passes urine from the bladder during urination. As men age, it’s common for the prostate to enlarge, squeezing the urethra and causing low urine flow, urgency, frequent urination and incomplete emptying. That’s known as benign prostate hyperplasia, or BPH. Cancer and BPH are distinct diseases. BPH alone does not increase the risk of cancer. In the early stages, cancer of the prostate shows no symptoms, confusing many men who assume it would interfere with urination, as BPH does. That can happen in the late stages, but it’s rare early on. I like to describe the prostate as being like an olive, with a pit. BPH occurs when the central core, the pit, grows to abnormal size. Cancer, on the other hand, tends to be found in the outer, fleshy section and behaves differently than BPH. We tailor screening and monitoring to each patient—there’s no one-size-fits-all. That’s why it’s so important to talk one-on-one with your doctor to assess important risk factors, including: Age (this cancer is most common in men over 55) African American ancestry Family history, especially if your brother or father was diagnosed Presence of a BRCA gene mutation, the same genetic precursor that increases the risk of breast cancer in women. So you should be screened if there is a family history of BRCA among your female relatives Unlike other cancers, there are few known direct links to lifestyle or other diseases with this one. For example, we know conclusively that smoking causes lung cancer. But we don’t have as clear a picture when it comes to the prostate. Diet alone has not been implicated, nor have vitamin E, selenium, lycopene and other factors that get attention in popular media. However, we do have compelling evidence that metabolic syndrome can contribute. A byproduct of our Western lifestyle, the term describes a collection of risk factors—belly fat and unhealthy cholesterol—that can lead to cardiovascular disease, diabetes and other disorders. Men with metabolic syndrome are nearly two times more likely to develop prostate cancer compared to healthier men. Unlike cancers with more definitive causes, prevention isn’t straightforward either. But I encourage all my patients to maintain a healthy lifestyle with good nutrition and exercise, to control weight, cholesterol and blood pressure. The resulting benefits for prostate health and beyond are many and very well documented. Prostate cancer is a disease that most men will get if they live long enough. But, in the vast majority of cases, it is not ultimately the cause of death. So screening and treatment protocols have changed dramatically in recent years. At MedStar Washington Hospital Center, we follow the latest guidelines from the American Cancer Society, the American Urological Society and others. We are very careful to reserve aggressive screening and intervention for men at the highest risk and for cases that are truly life-threatening. Screening priority depends on the age of the patient—we are more aggressive with patients aged 55–69 and less so for those over 70. The most common screening is the prostate-specific antigen—or PSA—blood test. It’s important to understand that the PSA is not a cancer test, as cancer is just one condition that can cause elevated PSA. Elevated PSA can also result from enlargement, infection and inflammation. The digital rectal physical exam also does not detect cancer directly, but it’s important for other reasons and definitely recommended for men as they age. We also look for biomarkers in blood and urine that can help bring the condition into focus. Later-stage symptoms can indicate if the disease has spread—typically to the bones and lymph nodes. Symptoms can include back and bone pain, blood in the urine, fever, chills, night sweats and weight loss, especially when it comes on suddenly. If we see a patient with one or more significant risk factors or symptoms, we approach it more aggressively, including biopsy. As in other parts of the body, cancer in the prostate happens when cells go rogue and multiply at an abnormal rate. During a biopsy, we use a needle to harvest a small amount of tissue for laboratory analysis. This is the definitive test—observing those cells under the microscope to determine if they are cancerous and life-threatening. Although biopsy is low risk, it’s not without risk. We are always careful to use it sparingly, when all the other indicators align. MedStar Washington Hospital Center and MedStar Georgetown University Hospital are the only hospitals in the region applying the most advanced biopsy techniques (such as transperineal biopsy) to limit risk to the patient from the procedure itself. Biopsy is quick and typically performed in the office using local anesthesia. We use rectal ultrasound to locate and visualize the biopsy site, since the prostate is very close by. For decades, the needle was passed through the wall of the rectum, but that can seed the prostate with bacteria and cause a potentially life-threatening infection. With the improved transperineal technique, the needle is passed through the perineum, the skin at the base of the scrotum. Fewer bacteria are present on skin, and sterilizing it is much more effective, nearly eliminating the risk of infection. Like diagnosis, treatment varies depending on age and risk. Because most men with the disease are likely to pass away from other causes, prostate cancer can often be monitored. Active surveillance is the most common strategy. We keep an eye on indicators, watch the PSA level and, on occasion, repeat the biopsy. If the disease isn’t progressing, it can be monitored indefinitely, without further intervention. With radiotherapy, we focus photons on the cancer cells to kill them or slow their growth by damaging their DNA. Traditional radiation is administered every weekday for 40 days. But at MedStar Washington Hospital Center, we use much more advanced treatments that safely deliver more radiation in less time, achieving similar results in as little as five days. We can also target diseased areas of the gland, limiting exposure to healthy parts. Testosterone and other male hormones fuel cancer cells. In some cases, we will also add androgen suppression therapy to temporarily reduce male hormone levels and starve the cancer cells. When surgery is found to be the right option, we use leading-edge, minimally invasive robotic surgery to remove the prostate. Robotic surgery can limit the hospital stay, usually to just one night, with less risk of urinary side effects. MedStar Washington Hospital Center and MedStar Georgetown University Hospital specialize in the technique of a “retzius-sparing” robotic prostatectomy, which expedites the recovery of urinary control. Side effects are not uncommon after treatment. The prostate is very close to the urethra and the nerves affecting sexual function, so the most common post-treatment problems are erectile dysfunction and urinary incontinence. This is why we are so careful in treatment planning, as both these conditions have significant lifestyle implications. We also have very sophisticated and effective treatments for the side effects that can improve function once the cancer is taken care of. Prostate care is a lot more effective than it was decades ago. We are one of the highest-volume centers in the region for prostate screenings and treatments. We use the newest, evidence-based techniques and protocols. And—most importantly—we have the experience to assess each man’s unique needs, risks and circumstances safely and accurately. We consider each patient to be a key member of the healthcare team. Working closely with you and your family, we make the best decisions for good health, together.

Sean Kimerling was a successful New York TV sportscaster and a lifelong athlete.  When he started to experience unexplained back pain, it was chalked up to an old sports injury. But the pain got worse. It was testicular cancer, discovered too late. We lost Sean in 2003, at age 37. The death of any young man in his prime is a tragedy. But Sean’s was particularly heartbreaking. If he had been diagnosed early, he likely would have lived a normal life. If you’re like most guys, you don’t even want to think about testicular cancer, let alone talk about it. But talking about it and getting educated could save your life. Testicular cancer is treatable. Survival rates for stage I diagnosis are as high as 99 percent. But the odds drop as the disease progresses, so early detection is absolutely critical. Cancer begins when cell production goes out of control. In healthy tissue, new cells surface as needed to replace older or damaged ones. With cancer, some cells mutate and replicate unchecked. Left untreated, these rogue cells can spread to other parts of the body, leading to cancer that is more difficult to treat or even death. Unlike other cancers, testicular cancer strikes young, healthy men. For men aged 30 to 39, it is one of the most frequently diagnosed types of cancer. All the causes are not well understood, but here’s what we do know: White men aged 15 to 44 are at risk, but it is rare among African Americans Men with a family history are at higher risk, as are those born with undescended testicles, even after surgical correction Men previously diagnosed have a slightly higher risk of cancer in the other testicle Research has uncovered no strong association with diet, exercise or occupational radiation exposure There’s no link between testicular and prostate cancer Past injury doesn’t seem to increase risk, but it’s not unusual for it to be discovered after trauma In its early, most treatable phase, it produces no pain and shows no outward signs. So, self-examination is our best defense. It’s simple, painless and could save your life. We recommend a self-exam every other month to check for signs. It’s easy to do, and it can be done in the shower or bath. Once you know the lumps and bumps of your anatomy—how your “normal” feels—you will be on guard for something firm and less compressible, almost like a small marble in the midst of normal tissue. You should also report any significant change in size, shape, or consistency. Your primary care provider can perform a more thorough exam. Most of the time, there is nothing to worry about. But if something is suspect, an ultrasound will be scheduled. If it turns up anything of concern, the next step is referral to a urologist. Urologists know what to look for, and we can also order special blood tests for tumor markers to better plan treatment strategy. Treatment almost always includes surgery. Other forms of therapy may be in order, depending on the stage. Stage I is when the mass is confined to the testicle, the most treatable form. Most men present this way, with treatment at a 99% success rate Stage II involves nearby lymph nodes as well, but the treatment odds are still good—at 96% Stage III has spread to other parts of the body, like the lung, heart or brain. Treatment success rate is 73%, but it’s rare for the disease to get this far before detection Unlike other cancers, this one has no stage IV. We don’t recommend biopsy—taking a sample of tissue for lab testing—as it can spread the cancer cells. The best course of action is removal of the affected testicle, a procedure known as radical orchiectomy. The tissue is tested and additional tests are administered on the pelvis, to identify the type and extent of cancer and determine if chemotherapy or other post-surgical treatment is needed. The testicles perform two major functions: producing sperm for reproduction and testosterone, which affects facial hair, musculature, and other hallmarks of the male sex. For most men, one testicle can do the work of two. The surgical procedure alone doesn’t generally affect testosterone production, semen quality, fertility or sexual function. Many men diagnosed with testicular cancer are at the age for starting or growing a family. We recommend a discussion about sperm banking to protect the reproductive legacy, in case future treatment puts sperm production at risk. A urologist specializing in fertility can complete a full evaluation. Sperm banking may not be covered by insurance, but it is inexpensive, and grants or other forms of financial aid may be available. Since most men present early, they don’t need chemotherapy or radiation, and their prognosis is very good. The procedure is generally very well tolerated, with a short recovery time. During the removal, the surgeon can implant a prosthesis, or artificial testicle, that looks and feels natural. Sexual function is rarely affected long term. Chemotherapy or radiotherapy can affect sperm quality and can cause fatigue that affects the mood for sex. After chemotherapy or radiotherapy, men should wait one year before trying to conceive to allow damaged sperm to clear from the body, and some men may not recover fertility after chemotherapy or radiotherapy. If surgery involved lymph nodes in the back, there is a small chance of complication that will prevent ejaculation. Although very rare, it’s another good reason to bank sperm. Most men treated early live normal, healthy lives. But since the risk of recurrence and other cancers is never zero, we recommend healthy lifestyle choices for the future, including maintaining good nutrition and a healthy weight; staying active and exercising; and limiting alcohol intake. Smokers are encouraged to quit, since tobacco use increases the risk of many other cancers and can complicate chemotherapy. It may seem a daunting prospect, but with early detection, testicular cancer is among the most treatable forms of cancer. The more you learn about it, the better prepared you will be. Ask your doctor for more information and keep doing self-exams. With vigilance and education, there’s no reason for this disease to keep you out of the game.

"You want to put your finger where? Why? Do you really need to do that?” I’ve heard many men say this or something similar after I recommend a digital rectal exam, also known as a DRE. I understand where they’re coming from. The test can be a little uncomfortable. But the value of DREs in detecting prostate cancer and other urological problems far outweighs a little awkwardness. That’s especially important for patients in Washington, D.C., We have the second-highest incidence rate of prostate cancer in the country and the highest number of people who die from the disease. A DRE actually is the second of two tests I use when screening patients for prostate cancer. The first test is a blood test for prostate-specific antigen, or PSA. Let’s go over how the two tests work together and what you can expect from a prostate cancer screening. https://ct1.medstarhealth.org/content/uploads/sites/135/2018/05/Dr-Krasnow-DRE-necessary-2.mp3 PSA is a protein that’s created by the prostate and present in semen. Small amounts of PSA naturally leak out into the bloodstream, but a higher-than-normal amount of PSA in the blood can indicate that a man may have prostate cancer. An elevated PSA level also can be sign of prostatitis (infection or inflammation of the prostate) or an enlarged prostate (also known as benign prostatic hyperplasia). When one of my patients has a high level of PSA in his blood, a DRE helps me understand and interpret what’s really going on inside the prostate. By feeling for any lumps or signs of cancer in the prostate, the rectum or nearby organs, I can get a better idea of whether my patient has prostate cancer, an enlarged prostate, or another condition. The combination screenings of PSA and DRE can tell us whether we need to move forward with more-invasive testing, such as a prostate biopsy. Click to Tweet Your doctor’s recommendation will depend on your individual risk for prostate cancer. Certain factors can increase your risk, such as being of African-American descent or having a father, son or brother (a first-degree relative) who was diagnosed with prostate cancer when he was younger than 65. The American Cancer Society recommends that doctors and patients discuss screening based on unique risk factors and following these general age guidelines: Age 50 if a man is at average risk Age 45 if a man is at high risk (African-Americans or one first-degree relative diagnosed with prostate cancer at an early age) Age 40 if a man is at highest risk (two or more first-degree relatives diagnosed with prostate cancer at an early age) If your PSA test is normal, you probably only need to have PSA tests and DREs every two years. An elevated PSA test might mean you need yearly screenings to make sure we don’t see evidence of prostate cancer. Men who are older than 70 usually don’t need a DRE or other prostate cancer screening. We also usually recommend against screening in men who aren’t expected to live at least 10 more years, as they’re less likely to benefit from treatment if we were to find prostate cancer because of the slow-growing nature of the disease. Of course, this is a decision only you and your doctor can make together. I typically use a mannequin to show my patients the area I’ll examine during their DRE. The prostate is a walnut-sized organ that sits right in front of the rectum, directly under the bladder. We can’t feel the prostate from outside the body, so the rectum is our best and easiest way to access it. During the exam, your doctor will wear a glove. They’ll lubricate their finger so the test is a little more comfortable. You’ll be undressed below the waist, either bending over the exam table or lying on the table on your side. The doctor will insert a finger and feel for any lumps or hardened areas on the prostate. The test takes just a few seconds to complete. You may feel like you have to urinate during the test, and there may be some discomfort. However, it usually isn’t painful. Though a digital rectal exam may be a little awkward, it plays an important part in the early diagnosis of prostate disorders and cancer. Ask your doctor about your risk for prostate cancer and whether you need to schedule this quick, potentially lifesaving procedure. Request an Appointment

Years ago, before we had advanced and routine imaging, a kidney mass was only discovered when it had become very large, caused pain or caused blood in the urine. Oftentimes, patients’ kidney cancer had already spread beyond the kidney when we discovered these masses. Today, we often detect kidney cancer by chance, when a patient has a CT scan or an ultrasound for another purpose, such as gallstones, indigestion or back pain. The imaging scan then will show a small renal mass that is localized, or confined to the kidney. At that point, the patient doesn’t have any symptoms from the cancer and the disease can be successfully managed and treated. Advances in treatments offer patients less invasive treatments and more successful outcomes. https://ct1.medstarhealth.org/content/uploads/sites/135/2018/05/dr_krasnow_-_min_invasive_for_kidney_cancer_2.mp3 Localized kidney cancers typically are not aggressive, so we have a variety of treatments that are effective and minimally invasive. The treatment option a doctor recommends will depend on the patient’s health and the characteristics of the kidney mass. Sometimes the best treatment is to actively monitor small, nonaggressive kidney masses with regular exams and tests every three to six months. If the tumor doesn’t grow or spread, we may extend the exams out to once per year. Active surveillance is a safe, non-invasive option for patients who: Are older Have other medical problems, such as diabetes, heart conditions, renal failure, or a single kidney Prefer to avoid surgery Have a small mass During active surveillance, we focus on general lifestyle improvements to reduce the risk of the cancer spreading. For example, I advise patients to quit smoking, lose weight, and work on controlling diabetes and overall wellness. If, after biopsy, we suspect a mass is cancerous, two of the least invasive treatment options are radiofrequency ablation and cryoablation. Ablation means the removal or destruction of tissues. In radiofrequency ablation, our colleagues in radiology put a needle into the area and burn the mass away. In cryoablation, they freeze the mass through the needle. These are good options for tumors that are small, and ablation will not damage nearby tissues or organs. In this traditional open surgery, we make a large incision in the front or the side of the patient. We remove the entire tumor and surrounding lymph nodes. For a smaller mass, we remove the cancerous part of the kidney while leaving the rest of the healthy kidney behind. We try to avoid this traditional open surgery if the size of the kidney mass or other considerations don’t make it necessary. That’s because, to get to the kidney, we have to make a very large incision, go through many layers of tissue and muscle and then reconstruct them after the tumor is removed. This risks more blood loss, longer hospital stay, a longer recovery, and other complications. In recovery, patients may have difficulty walking or breathing afterward because of how sore they are after the surgery. Today, open surgery is reserved for extremely large masses or evidence of local invasion. For a complete removal of the kidney, laparoscopy without robotic assistance is preferred over traditional open surgery, because there is less pain and a faster recovery. This is reserved for large masses that are not amenable to ablative techniques or partial kidney removal. We’ve made great progress in tumor removal with minimally invasive robotic laparoscopy. In robotic surgery, we manipulate robotic arms with instruments at a console to guide miniaturized surgical instruments to perform the operation inside the patient’s body. This newer technology allows for tiny keyhole incisions—between 0.5 and 1 centimeter each—either from the front or the back. Using the robotic surgery, we can remove the part of the kidney that is cancerous, while leaving the healthy kidney behind, a technique called “robotic partial nephrectomy”. We can also manage many locally advanced renal masses, such as those with evidence of vascular invasion robotically. Robotic surgery and traditional laparoscopy offer significant benefits to patients, such as: Better cosmetic results Less pain Quicker recovery Restart their diet earlier—even the next day Resume work and normal activities quicker Shorter hospital stays—usually one or two days after surgery Related reading: Latest Robotic Technology Brings New Benefits to Patients We encourage patients to walk but avoid heavy straining, heavy lifting, running, swimming or strenuous exercise until they’re approved for those activities. The last option for localized cancer is when we can’t spare the kidney. Traditionally, that would have required open surgery. Now, we often can do advanced-stage surgery using the robotic platform. One of the natural functions of your immune system is to identify and fight cells that are infected and remove cells that are abnormal. Cancer can escape these immune system defenses by changing receptors on immune cells—it basically turns off the immune response. Immunotherapy uses agents in your own body to improve or restore immune system function. These agents, called pd1 inhibitors or pdl1 inhibitors, can turn your immune response back on so that your body can fight the cancer again. This has been a revolution for kidney cancer specifically. Prior to the use of these agents, if a targeted therapy wasn’t working, there weren’t many other options. Now, immunotherapy is an alternative therapy for patients whose cancer seems to be spreading and for whom the first line of defense didn’t work. Immunotherapy is a good option for patients who have kidney cancer that has already spread. There are also immunotherapy clinical trials available at MedStar Washington Hospital Center for aggressive tumors that have been removed where the risk of recurrence is high. Click to Tweet I think the future of this procedure is twofold: The technology keeps progressing rapidly and we’re anticipating the next advancement, called the single-incision platform, which reduces the number of incisions we need for robotic surgery from four to one. Newer robots will be able to center that one incision in a single spot, such as through a belly button, leaving virtually no scar after surgery. We have started to treat more aggressive tumors in a minimally invasive fashion—even very large tumors that have extended into blood vessels. We are a research institute with clinical trials, so we are focused on advancements in technology and technique, and we are committed to treat every stage of kidney cancer. I understand kidney cancer is scary for patients no matter how early we detect it. But with the advances we’ve made in recent years, we have more tools available to us than ever before to catch these cancers early and treat them easier and more successfully for our patients.   Request an Appointment

Prostate cancer is the most common cancer in men, with one in seven men in the United States projected to get the disease in their lifetime. And the District of Columbia has the second highest prostate cancer incidence rate in the country behind only Louisiana, with 123 out of 100,000 men diagnosed with the disease in a given year. One of the best screening tools we have for this disease is the prostate-specific antigen (PSA) test. While there’s no doubt this simple blood test has saved lives over the years, it’s not perfect. There’s been a lot of debate over who should be screened and when—and whether men should be screened at all. Even national health organizations differ slightly on their PSA testing guidelines. PSA testing is not a one-size-fits-all approach to prostate cancer screening. The key is to have an honest conversation about the potential benefits and harms for each man based on his specific risk factors.https://ct1.medstarhealth.org/content/uploads/sites/6/2017/09/podcast-Dr-Krasnow-PSA-Testing-5-1.mp3 Prostate-specific antigen is a protein made in the prostate gland and present in semen. A small amount of PSA enters the bloodstream, but high levels in a man’s blood can indicate prostate cancer. After the PSA test’s introduction in the late 1980s, deaths related to prostate cancer began to decrease. In fact, mortality rates fell nearly 40 percent between the early 1990s and 2008.   This was a huge win in our fight against prostate cancer. However, there also have been some negatives associated with the test, the biggest being its 15 percent false-positive rate. A false positive is when the test detects cancer that is not present. This means 15 in 100 men who get an elevated PSA test result do not actually have prostate cancer. Unfortunately, to confirm this, they’ve likely undergone an unnecessary biopsy. While generally safe, biopsies can cause complications, such as bleeding or infection and can induce unnecessary stress for the patient.   PSA testing also can increase the risk of overtreatment. Most diagnosed prostate cancers are low-grade, which means the abnormal cells are unlikely to impact a man’s life in any way. Prostate cancer is a slow-growing cancer, taking 10 to 15 years to progress and even longer to cause death. These tumors may only need close monitoring over the years, also known as active surveillance, and not treatment. Do the potential benefits of PSA testing outweigh the potential harms? It depends on the person. Some of my patients who have received a false positive were relieved to know their cancer status for sure. Others, while relieved, continued to worry about their elevated PSA level as we monitored them over the following years. And still others were frustrated that they had to go through the biopsy process, which, while not painful, is awkward and uncomfortable.   Actor Ben Stiller made waves in 2016 with a blog post titled “The Prostate Cancer Test That Saved My Life.” In the article, he attributed surviving prostate cancer to having a PSA test at age 46—earlier than most guidelines would recommend—despite having no indicators that he was at increased risk for the disease.   He wrote: “If (my doctor) had waited (to get me a PSA test), as the American Cancer Society recommends, until I was 50, I would not have known I had a growing tumor until two years after I got treated. If he had followed the U.S. Preventive Services Task Force guidelines, I would have never gotten tested at all, and not have known I had cancer until it was way too late to treat successfully.” If you’re looking to various health organizations for guidance on when you should have a PSA test, you may be confused by the differing recommendations. And these recommendations also may change over time. For example, the U.S. Preventive Services Task Force slightly revised its guidelines since Ben Stiller had his PSA test based on new evidence and studies. Here is what some health organizations currently recommend: American Cancer Society: The organization recommends that men at average risk for prostate cancer begin discussing screening with their doctors at age 50. Men at increased risk should consider screening at age 45. American Urological Association: The organization recommends that doctors begin discussing screening at age 40 to 54 for men at high risk, 55 to 69 for men at average risk, and 70 and older for some men in excellent health with a 10- to 15-year life expectancy. U.S. Preventive Services Task Force: The group in 2017 recommended that while the PSA test should not be used routinely, physicians should discuss the benefits and harms with men age 55 to 69. It recommends against PSA screening for men 70 and older. This is in contrast to its 2012 guidelines that recommended against PSA screening in men without prostate cancer symptoms.   So what’s a man supposed to do? The answer lies in the common theme to these recommendations: a discussion between doctor and patient.   I once treated a man in his 40s who was exhibiting signs of benign prostatic hyperplasia, a condition in which the prostate is enlarged. We decided to do a PSA test, despite most guidelines recommending against PSA testing for a man younger than 50 with no increased risk factors for prostate cancer. The test showed elevated PSA levels, but a traditional biopsy only found very low-grade cancer.   This didn’t make sense considering his high PSA levels. We had a long conversation about how to proceed, and we decided to do advanced testing. An MRI-guided biopsy that is increasingly being used to detect prostate cancer revealed a high-grade prostate cancer that, left unchecked, would have been lethal.   PSA test guidelines aren’t hard and fast rules—as my patient and Ben Stiller would attest to. The key is an open, honest conversation in which the patient and doctor come to a decision together. Related reading: Shared decision-making: It’s no longer “doctor knows best” For a man at average risk for prostate cancer, the discussion may center more on the potential benefits and harms of a PSA test. However, the conversation may take on a more urgent tone if the man has factors that put him at increased risk for prostate cancer. These can include: Family history: Having a first-degree relative, such as a father or brother, who had the disease. Genetic mutations: We’re continually learning more about how certain gene mutations can increase a man’s risk for prostate cancer. This includes mutations of the BRCA1 and BRCA2 genes, which are more commonly associated with breast and ovarian cancers.   Race: African-Americans have double the incidence of prostate cancer compared with white men, and their risk of dying from the disease is two to three times higher. A man’s age also should be taken into effect. Because prostate cancer grows so slowly, there’s little benefit to screening older men whose life expectancies are less than 10 to 15 years. When I see a patient who is 70 or older and has been referred to me for a PSA test, I usually advise against it unless they are extremely healthy for their age.   I think as medical professionals, we’re doing a better job of screening smarter and being more selective in who gets a PSA test. But discussion is the key. Request an Appointment