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GreenField Health’s Health Matters: February 2006
Please Start With Your Name
Billing Statements from GreenField
Yearly GreenField Renewals
More on End of Life Planning
The Conundrum of Prostate Cancer Screening
Inguinal Hernia—To Repair or Not to Repair
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Please Start With Your Name
When you call our office, we are ready to assist you with whatever you need. All of our communication is entered into our state-of-the-art electronic medical record, which provides many benefits for you as a patient, and it keeps our office running very efficiently. Whether you need a medication refill, a referral to a sub-specialist, or to leave a message for someone in the practice, we enter all of that into our computer system.
In order to begin entering your information, we need to pull up your chart, so if you can start the call with your name, we’ll be sure to get all of the information entered into the correct place. We understand that it’s normal to start with your story, which we really want to hear….we’ll just be better able to record it and help you with what you need if we can put it all in the right place. Thanks in advance for helping us to help you better.
Billing Statements from GreenField
As a GreenField patient, you may receive a statement from us from time to time. Statements are sent only to patients who have a balance due to us after we hear from your insurance. If you receive a statement about a charge that you are not sure you owe, please call our billing coordinator, Beth Davis at 503-384-2005. She will be happy to assist you with your questions, and if appropriate, we will re-bill your insurance company.
We do mail out a receipt to you after we receive a payment from you. We recommend that you keep these for taxes or Medical Savings Account reimbursements. If you find yourself at the end of the year without receipts, please call or email Beth at beth.davis@greenfieldhealth.com to request a copy of your statement.
Yearly GreendField Renewals
Each year, we will send you a packet for your yearly renewal with GreenField. These are sent during the month of your anniversary of joining GreenField. Please take the time to review all of the information and send the renewal form back to us right away we promise that we’ve made the paperwork as minimal as possible. If you are on a payment plan via credit card with us, we ask you to let us know right away if your card number changes, and that you get us the new information whenever it expires.
More on End of Life Planning
In addition to the information provided last week on end of life planning and “advanced directives,” living wills are mostly governed by state law and you can find forms specific to Oregon on the Oregon Health Decisions web site at: http://www.oregonhealthdecisions.org/Pages/publications.htm.
Oregon also uses the Physician Orders for Life Sustaining Treatment or POLST form as another very effective document that specifies physician orders at the end of life. This form is of particular importance for those individuals approaching the end of life, for example those with a terminal illness. It is available at: http://www.ohsu.edu/ethics/polst/OR.shtml
The Conundrum of Prostate Cancer Screening
Prostate cancer is very common in men over 50, and can lead to death. There has been a tremendous amount written about prostate cancer in the lay press and that has helped shape opinions about whether prostate screening is helpful. Medical experts still disagree about whether prostate cancer screening is right for all men. They disagree about whether the benefits outweigh the risks of screening. Prostate screening has both advantages and disadvantages.
Understanding Prostate Cancer
Prostate cancer is rare in men younger than 50 with the risk increasing with age. Men who have a first-degree relative a father or brother with prostate cancer are more likely to develop it and it is more common in black than white men.
The prostate gland lies below the bladder and above the rectum in men and produces seminal fluid that helps carry sperm during ejaculation. About 230,000 men in the US are diagnosed with prostate cancer each year, and about 30,000 will die from this disease.
These numbers tell a curious story. Although a large number of men are diagnosed with prostate cancer, most of them do not die from it. While men have a 17% lifetime risk of being diagnosed with prostate cancer, only 3% of men die from the disease. Even more dramatically, autopsies show that 30% of men 50 years and older had undiagnosed prostate cancer.
Most prostate cancer either doesn’t grow or grows so slowly that the majority of men who have it die from other causes before it is diagnosed or before it causes any problems. In a large number of cases, the prostate cancer will never even leave the prostate and will cause no problems. However, a small number of prostate cancers grow quickly.
These factors lead to a confusing situation. The majority of cancers picked up by screening will never be a problem, and our current tests do not differentiate which cancers will and which will not cause problems.
Prostate Cancer Screening
Prostate cancer screening involves two tests – the rectal exam and the prostate specific antigen (PSA). A rectal exam is performed by the physician to feel the prostate for lumps or nodules. Most cancers are not identified on rectal exam however.
The second test is the prostate specific antigen, or PSA, which is a blood test. PSA is a protein produced by the prostate, and many men with prostate cancer have a PSA of greater than 4.0. However, a level greater than 4.0 does not mean that cancer is present because the most common cause for an elevated PSA is benign prostatic hyperplasia or BPH, a non-cancerous enlargement of the prostate which is very common in older men. Other causes of an elevated PSA include prostate infection – called ‘prostatitis’ and trauma. Trauma may be caused by vigorous bicycle riding or sexual activity for example. Generally speaking, the higher the PSA the greater the chance that cancer is present. Levels of 4.0 to 10.0 represent a gray area.
To add to the confusion over the value of screening, consider the following:
• About 20% of men over 50 with a normal PSA have prostate cancer detectable in their prostate when random biopsies of the prostate are performed. We call this a “false-negative” PSA test.
• Only 30% of men with an abnormal PSA have prostate cancer, meaning that there is a very high “false-positive” rate.
Thus, the PSA test is far from 100% accurate. Refinements in PSA blood testing such as measuring PSA velocity (rate of change over time) are intended to increase the accuracy of PSA tests, but there is not general agreement as to the additional benefits of such tests.
An abnormal rectal exam or an elevated PSA test is not a reason to panic. As previously mentioned, benign conditions are the most common causes for an abnormal PSA test and should be considered, particularly when the PSA is between 4 and 10. On the other hand, a positive test should not be ignored.
Other tests are available to evaluate the prostate. A prostate ultrasound can be done in a urologist’s office with about 80% of cancers being identifiable on ultrasound. It is not used as a primary screening test for prostate cancer, but rather as a guide to help determine if a biopsy is needed and to guide a possible biopsy.
Prostate biopsy is also a relatively simple office procedure that is usually performed without sedation or anesthesia using a biopsy gun. Like all the other tests, prostate biopsy also has flaws. Up to one in five men with a negative result on an initial biopsy may have cancer diagnosed on subsequent biopsies. In addition, prostate biopsy frequently identifies clinically unimportant cancers that would not otherwise cause problems.
The Pros and Cons of Screening
It seems intuitive that doctors would want to find cancer in their patients at the earliest stage possible. Unfortunately, in the case of prostate cancer, the situation is not so simple; even the experts cannot agree about the need for screening. There are a number of arguments for and against prostate cancer screening.
Arguments in favor of screening
• Even though many men with prostate cancer have the nonaggressive form and do not die of the disease, the cancer is common and a substantial number of men die from it every year, while many more have complications from advanced disease.
• For men with the form of aggressive prostate cancer, the best chance for curing it is by finding it at an early stage through screening and then treating it with surgery or radiation.
• We should detect prostate cancer early because the five-year survival for men who have prostate cancer confined to the prostate gland is nearly 100%, but it drops to 30% for men whose cancer has spread to other areas of the body.
• The available screening tests are not perfect, but they are easy to perform.
• Mortality due to prostate cancer has declined in recent years. It is possible that screening programs are partially responsible for this decline, although we cannot be certain.
Arguments against screening
• Despite the arguments for screening, there is little evidence that screening and treatment help men live longer or avoid the complications of advanced prostate cancer. No well-performed studies have determined that prostate cancer screening in the general population saves lives.
• Men face significant risks from being diagnosed and treated for prostate cancer when a high percentage of those cancers would never have caused problems.
• The high number of false-positive rectal exams and PSA tests leads to anxiety and necessitates further testing including possible prostate biopsy which is relatively safe, but does have side effects.
• The side effects of treatment for early prostate cancers detected by screening are substantial. Surgery and radiation therapy can cause erectile dysfunction and urinary and bowel problems. Many men will suffer significant side effects of surgery and radiation when the cancer itself would have never been a problem.
Recommendations
The United States Preventive Services Task Force and many European cancer societies have not endorsed routine serum PSA screening, while the American Cancer Society and American Urological Association do recommend screening. This lack of consensus arises from an inability to adequately assess the benefits of screening while recognizing that there are significant risks associated with treatment.
Clearly, these tests are far from perfect, but those who favor prostate screening should have a yearly rectal exam and PSA, followed by prostate biopsy if either test is positive. Screening typically begins at age 50, although men who have other risk factors such as black men or men with a father or brother who had prostate cancer may want to begin screening at 45. Screening is generally discontinued in men over 70 because such men are unlikely to live long enough to benefit from screening.
At GreenField, we know that there is no one right answer. Only you can decide what is best for you. We try to discuss these issues with each patient and help him make an informed decision based on personal preferences.
Inguinal Hernia—To Repair or Not to Repair
While there are several types of hernias, inguinal hernias in the groin area are the most common. They occur predominately in men and are generally surgically repaired. Traditional thinking has been that individuals with inguinal hernias should have them repaired to prevent pain and complications. However, a new and well-performed study published recently in the Journal of the American Medical Association reveals that “watchful waiting” provides the same outcomes as surgical intervention. Watchful waiting obviously refers to “just keep an eye on it and let me know if new symptoms develop such as pain.”
The results of the study showed that it is not necessary to repair an inguinal hernia until symptoms develop, and that deferring an operation is safe. This study also provided an up to date assessment of the risks with surgery. While the surgery has a very high success rate in terms of fixing the hernia, complications of the operation occurred in nearly a quarter of the men having surgery. For example, persistence of pain in the groin related to the hernia repair was found in about 4% of patients following surgery.
After two years of observation, the outcomes in the watchful waiting group of patients and the surgery group of patients were quite similar. The frequency of pain interfering with activities was the same in both groups, and their physical functioning was also the same. Both groups of patients reported less pain at the end of two years than when they first enrolled in the trial.
As the trial went on, some of the patients in the watchful waiting group developed symptoms and requested an operation. By the end of the 4.5 year observation period, a third had crossed over to receive an operation. When the operation was done, the outcomes for these crossover patients were just as good as the patients who received an operation right away.
Thus, inguinal hernias with minimal symptoms can be safely followed without proceeding to surgery.
As always, we thank you for the opportunity to assist you with your health needs, and we welcome your calls or emails if there is anything at all we can do for you.
Thanks to our corporate partners
Kryptiq Corporation
Baker-Ellis Asset Management, LLC
Stahancyk, Gearing, Rackner, & Kent Law Firm
Go to our website to learn more about these corporate sponsors https://securemail.greenfieldhealth.com/Portal/General+Info/Corporate+Partners/Default.aspx
First Tuesday Reminder
The schedule for our upcoming GreenField Health First Tuesday Open House is March 7th, April 4th, and May 2nd. This is a good introduction to our practice for relatives, friends or coworkers who might be interested in becoming a GreenField patient. The sessions begin promptly at 5:30 PM on the first Tuesday of each month. Learn more about our First Tuesday Open House Online at: https://securemail.greenfieldhealth.com/Portal/General+Info/First+Tuesdays/default.aspx
Sincerely,
Your GreenField Health Team:
Beth Davis, your Benefits Coordinator and Biller- beth.davis@greenfieldhealth.com
Chuck Kilo, MD - chuck.kilo@greenfieldhealth.com
Cynthia Ferrier, MD - cynthia.ferrier@greenfieldhealth.com
Dia Gaede, CMA, your Health Coordinator - dia.gaede@greenfieldhealth.com
Elizabeth Hays, MD - elizabeth.hays@greenfieldhealth.com
Eric Murray, MD - eric.murray@greenfieldhealth.com
Jill Arena, your Clinic Administrator - jill.arena@greenfieldhealth.com
Joel Swartzmiller, IT Manager - joel.swartzmiller@greenfieldhealth.com
Pam Mockenhaupt, CMA, your Health Coordinator - pam.mockenhaupt@greenfieldhealth.com
Paula Koeller, MD - paula.koeller@greenfieldhealth.com
Sarah Larson, CMA, your Health Coordinator – sarah.larson@greenfieldhealth.com
Shelly Banta, your Clinic Manager - shelly.banta@greenfieldhealth.com
Tiana Schmitt, CMA, your Health Coordinator - tiana.schmitt@greenfieldhealth.com
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GreenField Health System
9427 SW Barnes Road,
Suite 590
Portland,
OR 97225
Phone: 503-292-9560
Fax: 503-292-9510
Web: http://www.greenfieldhealth.com
Questions, concerns, comments appreciated:
questions@greenfieldhealth.com
copyright 2003-2006 GreenField Health
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