On PSA screening
Dr. Schellhammer’s views on PSA screening are based on his clinical experience and the scientific evidence that has been provided by clinical trials. “To say you’ll never get a PSA is, I think, putting your head in the sand. Yet to get a PSA and plunge immediately into various interventions is precipitous. The patient needs to gather information and make decisions based on his age, health, family history, quality-of-life expectations, and often subjective mindset.”
Following the recommendations of the American Urological Association guidelines for PSA early detection, Dr. Schellhammer said he believes a baseline PSA for a 40-year-old man is wise: If he tests below the median of 0.6 ng/mL, another PSA test at age 50 would be reasonable. “If that’s still low, prostate cancer that would cause morbidity or mortality within the patient’s lifetime is extraordinarily low and a discussion about discontinuation of testing could be considered. In reality, however, most patients are more comfortable with some periodic testing.
“At the other end of the spectrum is the 75-year-old who is in magnificent health and has family longevity. Although there is a recommendation to avoid PSA testing in such an individual, if he understands the issues about testing, I think it is reasonable to do so,” he said. “If he has an elevated PSA and is found to have high-grade disease, he should have the option of considering therapeutic intervention. Men with multiple comorbidities and a life expectancy less than 10 years, regardless of age, should be counseled against PSA early detection. These comorbid illnesses will be the cause of death long before prostate cancer,” he explains.
Being immersed in PCa in both his professional and personal lives does not add stress to Dr. Schellhammer’s situation. “I feel fortunate to have a disease about which I am knowledgeable and about which I counsel patients on a daily basis. I think I can help them by example, and can also appreciate what they’re going through and empathize with them.”
Andrew S. Levey, MD, a nephrologist in Boston who donated a kidney
Most doctors do not choose to live their specialty, but Andrew S. Levey, MD, Chief of Nephrology at Tufts Medical Center in Boston, volunteered to be in a six-person chain as one of three kidney donors, each of whose spouses would be the organ recipients (chronicled here). One of those recipients was his wife, hematologist/oncologist Roberta M. Falke, MD, who suffers from polycystic kidney disease (PKD).
“I got to make a choice, and for me, that was one of the most meaningful things going through the process,” reflects Dr. Levey, who underwent laparoscopic nephrectomy in December 2009. “Here I had a chance to do a good deed in my personal life by being able to choose to do the same thing that I have recommended for so many family members of my patients,” said Dr. Levey, who is the Dr. Gerald J. and Dorothy R. Friedman Professor of Medicine Tufts University School of Medicine.
“It was the confluence of achievement of personal and professional goals—having spent so many years dedicated to taking care of patients with kidney disease, having a great dialysis and transplant unit here at our hospital, having encouraged family members to help their loved ones by being kidney donors, and then having the chance to do the same thing myself. That was tremendously rewarding for me, and I think that’s my strongest feeling about this.”
After extolling the virtues of his facility’s transplant program for so long, Dr. Levey was able to practice what he preached by choosing to have his colleague of 25 years remove his kidney. “I trusted him from the day he and I started working together to take care of everybody, and I trusted him to take care of me.”
Although Dr. Levey had a smooth recovery and was back to work four weeks after the operation (his wife is also doing well), “I still have symptoms at the incision site and I’m still recovering as far as my physical activity,” he reports. “When I do something that I haven’t done since the surgery and I feel a little pull there, I go, ‘Oh, I remember that.’”
Knowledge can heighten stress levels
His deep knowledge of kidney transplantation only served to heighten Dr. Levey’s sense of uncertainty about the operation. “We know that this is safe on average, and we know that most people can expect to have a good recovery, and we know that as far as major health issues and survival are concerned, the donors do just as well as if they hadn’t donated,” he confirms. “But I don’t think we know everything that happens to donors. And I think our experience about donors comes from an earlier time when people were by and large healthier and younger than donors like myself. I was 59 when I did it.”
Still, Dr. Levey was more than willing to deal with that bit of uncertainty in exchange for “the certain knowledge that it would help my wife be better,” he says. “And I’m still willing to accept the uncertainty that comes with getting old with one kidney.”
Even if he had not chosen nephrology as his specialty, Dr. Levey would have been surrounded by renal issues: Two of his wife’s siblings also have PKD (one has received a donor kidney from an unaffected sibling), and it is now moving into the next generation of nieces and nephews.
Having illness in the family
“I had already decided that nephrology was the field that I wanted to go into, and my wife already had kidney disease when we met, so I don’t think it was an attraction for either of us,” he laughs. “But I’ve thought for a long time about what it means to have this illness in my family. Now I think that it may have affected my interests within the field, but those interests have been fairly strong toward clinical medicine and clinical research the entire time, and that fits very well.”
Dr. Levey’s work is focused on the complications of chronic kidney diseases in general, including PKD, and the clinical tests that estimate and measure kidney function and damage. He does not try to maintain expertise in PKD himself, however. “I’m very fortunate that one of my close colleagues here is very involved in polycystic kidney disease research and our hospital is a center for research in polycystic kidney disease, so I feel like just by being here I’m able to support those efforts without really doing it myself,” he says.
Organ donation, however, is a major concern to him as a nephrologist and as a loved one of current and future recipients. “Being a kidney donor helps only one person, and of course, it’s never enough,” he laments. “My wife still has polycystic kidney disease and even though she has a kidney transplant, her health problems are not over. And people in the next generation are going to have it. There’s only so much that only one person can do, either as a doctor or a donor.”
One solution is to promote more exchange programs, such as the one in which Dr. Levey participated. “That’s something that I’ve learned—that the exchanges help multiple people, and that we should encourage people to think about the exchanges and not exclude donors who have blood-group or tissue-type incompatibilities.”
Dr. Levey and his wife have each done a fair amount of speaking this past year to increase awareness among patients and the general public regarding the donor-exchange programs on behalf of such organizations as the National Kidney Foundation (NKF). (Dr. Levey is editor of NKF’s American Journal of Kidney Diseases). He said he is gratified to see that the federal United Network for Organ Sharing (UNOS) has just launched a pilot program to make kidney exchange a national endeavor (www.unos.org/about/index.php?topic=newsroom&article_id=2639:a5ba3316bac4c41c58615fbb5059395d).
“At the present time, we’re not encouraging donors who can give directly to their recipient to be part of the exchange program,” Dr. Levey says. “But I can foresee a time in the future when the benefits might be so clear that it would become an option for [more] people. Already, good-Samaritan donors are encouraged to give to the exchange program rather than specifically to the patient at the top of the deceased-donor waiting list. This can create multiple exchanges, and then the last donation in the exchange program will go to the patient at the top of the deceased-donor waiting list. So every donor who goes into the exchange program creates opportunities for multiple people to get a transplant.”