Business Insider explains one of the Republicans’ most egregious proposed changes in the tax code:
The Republican tax plan repeals an itemized deduction that applies to healthcare expenses. That’s key for families with high medical costs, like those dealing with chronic conditions that require medical devices and other expensive equipment. Right now, those expenses can be deducted from their taxes, but under the Republican tax plan, they wouldn’t be able to.
Under current law, individuals who spend over 10% of their income on medical expenses are allowed to deduct part of those costs from their taxes. The proposed new bill would remove that deduction. According to the Internal Revenue Service, for 2016 taxes, individuals were able to deduct in an itemized way “only the amount of your unreimbursed allowable medical and dental expenses that is more than 10 percent of your adjusted gross income [AGI].”
Who spends more than 10 percent of his or her AGI on medical expenses? Generally people at the end of life in nursing-care facilities, where many expenses are not covered by Medicaid or Medicare. CNBC reports:
“This would be a joke if the consequences weren’t so serious,” said Brad Woodhouse, campaign director of health-care advocacy group Protect Our Care, in a statement. “Republican leaders are determined to raise health-care costs for middle-class families who need it most — in this case people with high medical costs or those paying for long-term care.”
While it’s not a widely used tax deduction — about 5 percent of tax filers claim it — for the old and sick it can be significant.
It tends to be mostly … older people who do not have long-term care insurance, and end up in a nursing home,” said Richard Kaplan, a professor who specializes in tax policy and elder law at the University of Illinois College of Law.
The cost of living in a nursing home can easily run up to tens of thousands of dollars per year and wipe out the savings of elderly residents who are paying out of pocket. The deduction can be an important offset to taxes those Americans would owe on their retirement savings distributions.
“For people who are receiving long-term care and are paying for it themselves, this is going to be a huge deal,” said Kaplan.
Andy Slavitt, former head of the Centers for Medicare and Medicaid Services, tells me, “The medical deduction is one of the most popular and important tax credits, particularly for all of us as we age.” He adds, “It keeps many seniors and families out of bankruptcy when in need of end of life care. Ask anyone with chronically ill kids, parents, or spouses.” These are not only very sick, old people but very sick, old and non-rich people. (“AARP has calculated that about three-quarters of those who claim the medical expense deduction are 50 or older, and more than 70 percent have incomes $75,000 or below. Many of those expenses are for long-term care, which is typically not covered by health insurance. Long-term care can cost thousands or tens of thousands of dollars a year.”)
This move doesn’t recoup much revenue in the grand scheme of things. (“It will cost the government about $10 billion a year in lost tax revenues in 2018 and about $144 billion over the next 10 years.”) So why do it? Well, Republicans have given so many tax breaks to the rich and corporations that they are scrounging for ways to take benefits away from others.
Consider this: The giveaway to rich heirs by removing the estate tax and allowing heirs the “stepped-up basis” adjustment in assets comes to $300 billion. They are literally taking money from nursing home residents so that rich heirs won’t have to pay a dime of inheritance taxes on estates exceeding $11 million (for a couple).
Or think about elimination of the alternative minimum tax, something that costs President Trump and other very rich individuals millions or tens of millions. Repealing it would cost $695.5 billion. Literally, they are taking money from people in nursing homes so that Trump and people like him can pay less in taxes.
There’s only one word to describe this sort of trade-off: obscene.
[A] new generation of immune-boosting therapies has been hailed as nothing short of revolutionary, shrinking tumors and extending lives. When late-stage cancer patients run out of other options, some doctors are increasingly nudging them to give immunotherapy a try.
But that advice is now coming with unintended consequences. Doctors who counsel immunotherapy, experts say, are postponing conversations about palliative care and end-of-life wishes with their patients — sometimes, until it’s too late.
“In the oncology community, there’s this concept of ‘no one should die without a dose of immunotherapy,’” said Dr. Eric Roeland, an oncologist and palliative care specialist at University of California, San Diego. “And it’s almost in lieu of having discussions about advance-care planning, so they’re kicking the can down the street.”
Palliative care and oncology teams have long been wary of each another. For many oncologists, palliative care teams are the specialists to call in only when curative treatments have been exhausted. For many palliative care specialists, oncologists are the doctors who prescribe treatments without regard to quality-of-life considerations.
But the new collision between immunotherapy and palliative care experts comes at an inopportune moment for health care providers, who have in recent years promoted palliative care as a way to increase patient satisfaction while reducing costs associated with hospitalizations and emergency room visits.
Dr. Cardinale Smith, an oncologist and palliative care specialist at Mount Sinai Hospital in New York, said she has seen a handful of patients who tried immunotherapy treatments after failing chemotherapy, and who were later admitted to the hospital in poor condition. Almost all of them died there, without having been asked about where, and under what conditions, they might prefer to die.
“These conversations are not occurring because of the hope that this will be the miracle treatment,” Smith said. “Unfortunately, on the part of the oncologist, treatments like immunotherapy have become our new Hail Mary.”
Immunotherapies work for only around 15 to 20 percent of cancer patients who receive them.
They have been approved by the Food and Drug Administration for Hodgkin lymphoma and certain cancers of the lung, skin, blood, kidney, bladder, and head and neck — but not for common cancers like prostates and most cancers of the colon and breast. A new type of immunotherapy, CAR-T, was approved earlier this week for leukemia.
But even for those cancers, oncologists and patients sometimes refuse to acknowledge clear signs that immunotherapies are failing, said Dr. Sandip Patel, a cancer specialist and immunotherapy researcher at the University of California, San Diego.
Patel said he now engages home-based palliative care specialists, who can provide supportive care while a patient’s health is relatively stable. “Then, at least when they transition to hospice, it’s not as much of a free fall out of the traditional health system, and if they’re one of the patients who respond to the therapy, great.”
He lamented the fact that patients who fail immunotherapy treatments spend more time in hospitals than with their families at home. “The flip side is, if I had a cancer with a 15 percent response rate, and if the benefit might be longer-term, I’d try it,” he said. “Who wouldn’t buy a ticket to a lottery of that importance?”
But not all patients have a clear idea of what that lottery ticket might cost them. Carrie Clemons’s father, Billy Clemons, who is 68 and is a former Texas state representative, last year stopped responding to chemotherapy for renal cell cancer that first struck him in 2002. His doctors recommended the immunotherapy Opdivo, which had recently been approved for his cancer.
At the time, he was symptom-free from his cancer, though scans showed it had spread to his lungs and some lymph nodes.
Two infusions of the drug, Clemons said, were followed by “eight months of hell,” during which her father became incontinent and had to use a wheelchair, lost his eyesight and most of his hearing and speech, and endured multiple weeks of intubation and care in the ICU. When his heart stopped beating, he needed to be resuscitated.
While immunotherapies trigger debilitating side effects much less frequently than chemotherapy, they can spur potentially life-threatening conditions, depending on the cancer type and the treatment approach. Fewer than 5 percent of patients overall face serious side effects, for instance, but more than one-third of melanoma patients who receive a combination of immunotherapy drugs can experience such conditions. The upside: Half of those melanoma patients will see their cancer shrink for at least two years.
Clemons’s doctors at Houston’s MD Anderson attributed the reaction to a runaway immune system that essentially attacked his central nervous system. To reverse it, he needed weeks of therapy to replace his plasma with that of donors, to clear away his blood’s overly active antibodies.
He slowly improved, though, to the point where only some slight vision impairment remains, and doctors recently declared his cancer in remission.
Although the family is thrilled at the outcome, Clemons said, they had little idea when they began that such side effects were possible, and doctors never engaged the palliative care team to either discuss side effects or help manage them.
She wouldn’t have known to ask about such care. “I always just equated palliative care with hospice,” she said.
Hospitals overall have made some headway in integrating oncology and palliative care specialists, with more oncologists referring patients to palliative specialists to help them ease side effects of treatments and achieve quality-of-life goals.But Roeland, the doctor at the University of California, and others say the integration is less smooth when it comes to cutting-edge cancer treatments.
Palliative care teams have not been able to keep abreast of the breakneck pace of cancer treatments, so they may not be offering up-to-date counsel to patients who ask about possibly life-changing therapies.
Meanwhile, most of the growth in palliative care medicine has happened among clinicians who work in hospitals, where they generally see only those who have done poorly on immunotherapies, for instance.
“They’re not seeing the super-responders,” Roeland said. “So their first reaction usually is, ‘Why would you do that?’”
Roeland understands more than most the seductive qualities of an eleventh-hour immunotherapy gambit. He had given up hope of curing Bernard “Biff” Flanagan, 78, of his esophageal cancer in late 2015, and referred Flanagan to hospice care to help him manage his extreme weight loss, fatigue, and the emotional distress he felt from not being able to swallow.
But Flanagan, who speaks with the gruff, seen-it-all humor one might expect from a career FBI agent in LA, wanted to keep seeking a cure.
Roeland said he knew that many hundreds of clinical trials were testing the therapies on other cancers, so he did some digging. A paper from a recent cancer conference showed that some people with squamous cell esophageal cancer responded to immunotherapy. He could arrange to get the drug through the Bristol Myers Squibb, for free.
He presented the idea to Flanagan and his wife, Patricia, with the caveats that it might not work, and could come with possibly significant side effects.
Flanagan jumped at the chance. Patricia, a former professional photographer, was less enthused.
“I ran into her later in the coffee shop,” Roeland said. “She looked at me like. ‘What the hell are we doing here? He doesn’t have a good quality of life.’ I’m feeling guilty now.”
Roughly six weeks into the treatment, Flanagan’s energy was returning, and he found himself at the fridge. “I grabbed a glass of OJ, knocked it down, swallowed it no problem,” he said. “And it was like a miracle. I had another one.”
Now Flanagan has no symptoms, and he experienced only the briefest side effect: a skin rash that abated with ointment. Patricia recently helped him dispose of the morphine and other medications the hospice team had given them.
“If he’d died in the hospital, I would’ve felt terrible,” she said. “If I were in his place at that point, I’d have tried to arrange to die at home at my own choosing, but Biff just didn’t have as strong feelings about that as I had.
“I had little hope that he was going to recover, but it’s just been amazing. He really is living the life he’s always lived.”
Roeland said that for the experience “is so immensely rewarding that it drives an oncology practice. It can be 1 in 100 that happens like that, and you say, well, is it worth it?”
Like many young women, Emily Yates has tattoos, tinted hair, a love of fashion and a great sex life. She also happens to have cerebral palsy
By Emily Yates
I think it is fair to say that the Paralympics have changed perceptions for the better in linking disability and sport. We have become used to watching elite athletes win medals and represent their countries in front of large crowds, and they just happen to use wheelchairs or prosthetic limbs, or be of short stature, or have hearing and visual impairments.
But what happens when we change “sport” to “sex”? Does awareness and education exist in the same way?
Inclusive and accessible sex education certainly did not exist when I was at school – apart from, perhaps, putting a condom on a banana. We are aware that disabled women, in particular, are almost three times as likely to be sexually abused than their non-disabled peers and yet those of us with disabilities are still entering lessons and workshops that are not designed for us. There are few, if any, subtitled and audio-described videos, information is usually not easy to read or understand, and the bodies in these videos and photos rarely, if ever, reflect disability of any kind, further alienating those of us classed as less than normal, and often less than attractive.
My twin sister and I were born 10 weeks early with cerebral palsy and I became a wheelchair-user at the age of nine after corrective surgery on my legs.
Like many of my friends, I have been in situations where I felt vulnerable sexually, but one in particular was exacerbated by my disability. I am well able to stand up for myself, but I was in a taxi, with my wheelchair in the boot, and the taxi driver was totally inappropriate and very suggestive. Knowing that my disability hindered me in dealing with his approaches was horrible. I decided to keep talking politely to him in the hope that I could distract him through small talk, which I did, until he dropped me off.
I reported him, but it highlighted the difficult situations you can find yourself in sexually if you have a disability.
Children and teenagers are constantly told to respect themselves and others, but if you are disabled, it is likely that many of the adults in your life might never consider you as a sexual being, meaning that the usual safety advice and strategies are rarely discussed. You are doubly vulnerable if you can’t physically remove yourself easily from an awkward situation.
I have been fortunate enough to have great sex and talk about it, but it wasn’t easy for me. Before losing my virginity pretty late, when I was 19, my main concern wasn’t the act itself, but the positions that would be possible without causing a great amount of pain. I also worried that the passion would totally disappear after a bit of inevitable planning.
There were very few helpful answers on the internet, so that left one avenue: laughing and crying with my auntie and sister on a Sunday afternoon as we went through possible positions together … no doubt a story that will surface should I ever get married.
Although it was a giggle and it helped a lot – thanks, guys – it is also tragic that I had to get myself in such a panic over something that is supposed to be sexy and fun because I simply didn’t know where, or who else, to turn to.
Most people, disabled or not, go through a transition stage in which they are suddenly aware of others’ attraction to them and their desire to be attractive in return. For me, this happened quite late and I tended to leave getting the guys to my sister, who was, I have to say, very successful at it (she is about to get married). Although I’m over the moon for her now, I can see that I was pretty jealous of her victories with boys at the time.
As I have got older, learned that necessary patience and had great sexual experiences, I have also grown in confidence, although I still have some way to go until I am as self-assured as I would like to be when it comes to romance and intimacy.
Some people still think that disability isn’t sexy or, worse, having sex with someone who has a disability is seen as wrong. There is also still a sense that if you have a disability, you are ill or frail, neither of which fit into the traditional idea of what we consider sexually attractive in our society.
But change is coming and I am proud to be a part of that.
My sexual experiences have resulted in an awareness of myself as a woman that no one can take away – and that is a great place to be, disability or not. But it is important to remember that those experiences don’t come easily for young disabled people. For so many years, I have had more important things than being sexy to concentrate on. Other teenagers tend not to have to think twice about whether they are able to go on school trips, or prove they can go to university – physically travel there, rather than just reach the required academic standards, find accessible accommodation and work out travel arrangements.
My confidence has been boosted enormously by taking control of my life, and this has helped me in my job as a travel writer. When I volunteered at London 2012, I sat next to Sebastian Coe at a press conference and asked him for 15 minutes of his time and all the contacts he could give me. He, in turn, mentioned me in his speech at the closing ceremony for saying that the Paralympic Games had “lifted the cloud of limitation” for those with disabilities.
I went on to do a two-year consultancy with MetroRio on accessible underground travel and wrote an accessible-travel guide to Rio de Janeiro with Lonely Planet in preparation for the 2016 Olympic and Paralympic Games. I am the founder and one of the directors of My Purple Compass, a company that encourages people with disabilities to travel far and wide, journeying out of their comfort zones.
I also work with Enhance the UK, which, through the Love Lounge, is providing the sort of information I would have loved as a teenager. Change is slow, but it is happening, and we are able to help others to discuss important issues, such as the positions and pain worry I had years ago, through to whether disclosing a disability on an online dating site is a good idea.
Sex education for disabled children and teenagers must be taught in schools as a matter of course, and parents and other family members can play a big part by making it as important for disabled people as for everyone else. More sexually active disabled people in popular culture would also help to change all those perceptions of disabled people, and illustrate that we enjoy sex as much as anyone.
Although being a disabled woman is currently what my work is based on, I’m much more than a girl in a wheelchair. I have the same tatts, tinted hair and love of fashion as many women my age, and I hope that others see that as well as the wheelchair. I am learning that disability and sex are not mutually exclusive and I love the journey that comes with it.
A new clinical trial is set to begin in the United Kingdom using the powerful noses of dogs to detect prostate cancer in humans.
While research has been done before, these are the first trials approved by Britain’s National Health Service.
The trials, at the Milton Keynes University Hospital in Buckinghamshire, will use animals from a nonprofit organization called Medical Detection Dogs, co-founded in 2008 by behavioral psychologist Claire Guest.
“What we’ve now discovered is that lots of diseases and conditions — and cancer included — that they actually have different volatile organic compounds, these smelly compounds, that are associated with them,” Guest tells NPR’s Rachel Martin. “And dogs can smell them.”
The dogs offer an inexpensive, noninvasive method to accompany the existing blood tests for prostate cancer, which detect prostate-specific antigen, or PSA, Guest says.
“It’s a low false-negative but a very high false-positive, meaning that 3 out of 4 men that have a raised PSA haven’t got cancer,” she explains. “So the physician has a very difficult decision to make: Which of the four men does he biopsy? What we want to do is provide an additional test — not a test that stands alone but an additional test that runs alongside the current testing, which a physician can use as part of that patient’s picture.”
The samples come to the dogs — the dogs never go to the patient. At the moment, our dogs would be screening about between a 0.5- to 1-ml drop of urine [or 1/5 to 1/10 teaspoon], so a very small amount. In the early days, of course, we know whether the samples have come from a patient with cancer or if the patient has another disease or condition, or is in fact healthy.
They come to the dogs at our training facility. They’re put into a carousel, and the dogs go around smelling samples. If they come across a sample that has a cancer smell, they’ll stop and stare at the sample and wait. They won’t move on.
On dogs’ sense of smell
Dogs, as we know, have got this fantastic sense of smell. They’ve got 300 million sense receptors in their nose — us humans have a sort of poor 5 million. So they are fantastic at smelling odors at very, very low levels.
On how a dog detected Guest’s own breast cancer
I had a dog who was — and still is — our most reliable prostate cancer detector dog. She was working on a project with me, but she started for a short time to be a little bit anxious around me, and one day kept jumping and staring at me and nudging into my chest. I found a lump which I hadn’t been aware of.
I sought medical advice. Actually, that particular lump was fine, but I had very, very deep-seated breast cancer. I had surgery and treatment, and I’m glad to say I’m fully recovered.
But it happened at a time when there was a huge amount of skepticism about whether dogs could in fact add anything the future of the diagnosis of cancer. It kept me focused on the fact that I knew that dogs could offer something, if we can diagnose for cancer by screening noninvasively, screening for volatiles. And of course, this could save thousands of lives in the future.
I thought I’d take a moment and share with you a resource that has come my way.
This guide aims to help make the federal grants available to seniors, veterans, and disabled people much easier to understand and take advantage of, particularly for remodeling homes for accessibility.
Click on the image below to access the guide
The reasoning behind Expertise.com is to help people make truly better decisions by clearly laying out their options, with content written by industry experts. Because of their non-biased approach, they’ve been a trusted source for government entities and organizations throughout the US. Many publications and businesses already use our guides as resources for their readers.
So give it a look-see. I think you’ll be impressed.
According to the American Pain Foundation, there are more than 50 million Americans living with chronic pain. What is unfortunate however is that chronic pain is often improperly treated – or not treated at all. Those with chronic pain will tell you that they feel that there is a war being waged against those who are truly in pain. The answer is to find treatments that work, empower yourself and educate those in the community.
As a nurse with more than 30 years of experience I have witnessed more than my share of pain. During my student nurse days I remember the days of “Brompton’s Cocktail”. It originated in London’s Brompton Hospital and was a concoction made with morphine, cocaine, alcohol and chloroform water. It gained popularity in the 1970s through the Hospice movement with support of Elisabeth Kübler-Ross. However, with advancements during the 21st Century it no longer exists. I personally am glad, as from what I witnessed it did appear to reduce the patient’s pain however at a cost of the ability to have a level of awareness. The patient would be nearly in a coma from sedation. We have come a long way in the ability to control pain effectively. Obtaining and maintaining a proper dose however is another story.
In 2006, the American Pain Foundation surveyed their members and discovered that over 60 percent experienced breakthrough pain while taking routine pain medications. In addition, 75 percent also suffered from insomnia and depression. Activities of daily living were affected with over 25 percent indicating that even driving a car was too difficult to do.
That organization developed the Pain Care Bill of rights and encouraged patients to take an active position in their treatment plan. In my previous position working with chronic pain patients, I would frequently obtain guides and resource items from them to share with their healthcare providers.
In 2011, the Affordable Care Act required the Institute of Medicine to do a study about pain management. In that study it was reported that more than 100 million Americans are suffering from chronic pain. That is staggering and the highest numbers to date.
Despite the growing number of people that are in pain, the war on drugs rages on and in its path there is a tremendous amount of collateral damage. Patients that are truly in pain suffer, and organizations that become advocates and partners cannot sustain themselves. Regrettably in May 2012, the American Pain Foundation dissolved their organization due to lack of funding. They transferred a good deal of their education to other organizations and support groups in hopes of continuing their cause.
Their Pain Care Bill of Rights was a groundbreaking proposition in my opinion. It was an attempt to empower those in pain to take an active role in their care. One of the key concepts was the right to have your pain reassessed regularly and your treatment adjusted if your pain has not been eased.
Because of society’s drug addicted behavior, there have been more and more restrictions placed that are making it difficult for those in chronic pain to obtain relief. Misguided state and federal policies are restricting access to appropriate medical care for people in chronic pain. It is deterring even the most compassionate medical providers from treating anyone with pain conditions for fear of governmental scrutiny and penalties.
Better ways to manage pain are continually being developed. With relief as the goal, patients usually try various pain management techniques (often in conjunction) before they determine what works best for them. It is a very individual thing and may change over time.
There is a myriad of available medications that can be prescribed. From over the counter analgesics like NSAIDS (Motrin and Aleve) to Narcotics (Morphine, Hydrocodone, Codeine). While pain medications will assist in reducing the pain they do little to change the cause other than perhaps NSAIDS that may reduce swelling. As time goes on doses are often increased due to tolerance and often there are side effects such as constipation and stomach upset.
Exercise can assist with pain relief in individuals with arthritis. Yoga, tai chi and water aerobics are all very helpful. Some with Fibro and chronic headaches may find the stretching portion helpful.
Massage can reduce pain, increase tissue circulation, relax tight muscles and reduce swelling. In addition it can reduce anxiety and depression and help promote a better night’s sleep. Patients with headaches, arthritis and traumatic injuries will find this helpful. Those with Fibro may find it too painful. Cranial-Sacral work or Reiki may be more appropriate.
This uses a combination of combination of visualization, relaxation, visualization, and feedback from a machine that may help you to gain control of pain. Electrodes are attached to you and plugged into a machine that measures your muscle tension, blood pressure and heart rate. In time you are able to control your thoughts and tension and thus reduce pain and anxiety. It is very effective with headaches.
Transcutaneous electrical nerve stimulation uses low voltage electrical stimulation to block pain signals to the brain. This is accomplished through the placement of small electrode patches on the skin that is attached to a portable unit that emits a small electrical charge. It is used for pain in a localized area. Individuals with nerve pain such as diabetic neuropathy or trauma may find this useful.
Meditation / Relaxation
Through the use of guided imagery and meditation techniques, muscles can have reduced tension and general relaxation. Those with all forms of pain will find this helpful especially headaches and nec/back pain.
Yoga type diaphragmatic deep breathing involved clearing your mind and focusing on slow deep breaths that are rhythmic. This method of breathing involves breathing in and out, slowly, deeply, and rhythmically. It is through its process of inhaling through the nose and exhaling through the mouth you can release tension and induce relaxation. All those in pain will find this helpful.
Warm water baths or hot tubs can be soothing and relaxing for muscle and joint pain. Water aerobics is often easier on the joints and can increase range of motion. Patients with arthritis and fibromyalgia may find this helpful.
Hot showers or baths, hot packs, heating pads and paraffin wax baths to hands and feet are especially helpful with arthritic pain.
Cold therapy is a preferred treatment for some people as opposed to heat therapy. Most chiropractors will advice to use cold to reduce swelling and numb the pain to local injuries. Cold compresses or the simple act of wrapping a plastic bag filled with ice cubes, or frozen gel packs can be applied locally. Those with Reynaud’s should avoid the cold.
Pain Management Clinics
Pain clinics are for those who cannot be helped by medical and surgical treatment options by their primary doctors. It usually involves prescription drug management, physical therapy, nerve blocks and relaxation therapy. Often primary care doctors will refer you to such a clinic for pain management if you suffer from chronic pain. This is twofold. It may help to reduce your pain while allowing the attending doctor to eliminate having to explain his pain prescriptions to state and federal agencies!
Sometimes connecting with others that have similar circumstances can not only provide a wealth of information but inspiration to keep going. Only another person experiencing the same level of struggle can understand.
Take home message
Encourage your health-care provider to inform you about the possible causes of your pain, and possible treatments including alternative therapy. Request to have your pain be reassessed regularly and your treatment adjusted if your pain has not improved. Request a pain management referral if your pain does not subside.
Are there other methods you have used to reduce pain? Please leave a comment and explain your experience. Complete Article HERE!
Six years ago, after celebrating my 50th birthday, I chose to begin an annual ritual of having my prostate-specific antigen (PSA) level checked. I have been a practicing academic oncologist with a clinical practice that is devoted exclusively to prostate cancer for 25 years. I also have a PhD in health policy. My dissertation found that older men who are diagnosed as having prostate cancer are less likely to have complete staging evaluations and are also less likely to undergo a prostatectomy or radiation therapy as treatment.
At that time, my PSA level was 1.5 ng/mL (to convert to micrograms per liter, multiply by 1.0), raising some concern. One year later, I had my PSA level checked again; it was 2.5 ng/mL. I met with a urologist, a faculty colleague with whom I had collaborated on research, and requested a biopsy, which was performed 6 weeks later. I was anxious: did I have cancer? If so, what was my Gleason grade? How much tumor? I had treated hundreds of patients with prostate cancer and had seen thousands of prostate biopsy specimens, but now this was my biopsy. Two days later, I called the pathologist, another faculty colleague, anxious to hear the results. The slides had just finished processing. Would I want to look at the slides myself? I ran downstairs, sat at the microscope table with my friend, and together we were the first to see the cancer. Gleason 3 + 3 in 1 of 12 biopsy specimens, 5% of the gland, and no evidence of lymphatic, seminal vesicle, or extraprostatic involvement.
Now, what do I do? I had counseled hundreds of men with similar biopsy results. Most of the men my age had opted for surgery, a small number opted for radiation therapy, and a smaller number chose active surveillance. I chose to be an informed patient and got an opinion from leading medical, surgical, and radiation oncologists throughout the country. In the end, I decided to undergo a radical prostatectomy. My selected urologist was a national leader. I came away from a discussion with him believing that a prostatectomy, performed by him on a healthy person like me, would have an extremely low risk of sexual, bladder, or bowel dysfunction and 100% 20-year prostate cancer–specific survival. I chose surgery, viewing the risks as small and the benefits as great.
Fast forward 5 years: cancer free. However, as a result of the surgery, my right arm and right leg are permanently weak, with this deficit appearing immediately after surgery. The reasons for this outcome are unclear. My PSA level remains 0, but my daily 5-mile jog is no longer possible.
Where am I now on the PSA dilemma in light of the recent US Preventive Services Task Force recommendations? It is clear that prostatectomy results in a very high chance of 20-year prostate cancer–specific survival, but even when the procedure is performed by an expert urologist, it can also result in significant rates of sexual, bladder, and bowel dysfunction and other less common adverse effects, such as my weakness. Active surveillance with longitudinal PSA tests and physical examination is associated with very low rates of bowel, bladder, and sexual dysfunction and has a high probability of correctly identifying when to move from surveillance to treatment. If I could do it all over again, I would not undergo the surgery; instead, I would opt for active surveillance. Even the most informed patient (me in this case) has difficulty making a truly informed decision.