Ok so, I contacted my Urologist Dr. Marks at UCLA because I wanted to get a Color Doppler Ultrasound. He basically said the MRI that I already had is better than the Color Doppler and there's no need for a Color Doppler?
I'm thinking I need a new Urologist at UCLA, can anyone recommend one?
Thanks!
Marks is my urologist. IMHO the best if you are on active surveillance. Not exactly Mr Personality, but he knows his stuff. He's right that MRI is better than CDUS. Why do you think differently?
I just wanted another scan to help track the PCa. I have the first of 2 HDR Brachytherapy sessions monotherapy on 2-7-2020.
Why do you want a less sensitive scan when you are already getting a more sensitive scan? They use CT scans to plan and track placement for HDR brachy.
You don't think it's worth getting the scan?
The question is - why do you think it's worth getting a less sensitive scan? Any scan is only worth getting if it makes a difference in treatment. Are you being treated by Albert Chang? If he doesn't ask for it, why would you?
Elementary knowledge of statistics say that the higher the number of samples the narrower the confidence distance. Maths and statistics are not the fields of excellence of docs.
Well said!!!!
I have found the opposite - that doctors who publish understand statistics well. Yes, it's true that multiple MRIs would increase the confidence that the reading is correct- but the confidence is pretty good and doesn't justify the cost and bother of multiple tests.
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Elementary knowledge of statistics say that the higher the number of samples the narrower the confidence distance.
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That's true if the samples are independent. If, for example, you were sampling the prostate for tumors, and doing it "blind" -- no TRUS or MRI guidance. Then 16 cores gives you more information than 8 cores.
But let's say that you had an MRI, and took biopsy samples _based on the MRI_, so you ignored the places the MRI said were normal. And you find a Gleason 8 tumor, where the MRI said to look.
Now the patient says:
. . . "But doc -- I want you to also do a "blind" biopsy, to increase the sample count, and be more certain of the results."
The doc is justified in saying:
. . . "We did the MRI, and biopsied the spots most likely to be cancerous, and we
. . . . got a Gleason 8 core.
. . . . There's only a very low chance that a "blind" biopsy will find
. . . . something that we missed,
. . . . and that will affect your treatment.
. . . . The "blind" procedure has dangers and costs, and the benefit isn't worthwhile."
I think that asking for an ultrasound scan is in the same class of things:
. . . They cost money, and aren't likely to show anything new.
. Charles
Yes cpcohen, I know the (claimed) "rationale" behind this kind of thinking:
Accuracy and importance "should" be interrelated. And mostly they are.
But, when a breach between the two occurs, some accident may happen.
The most common excuse after the latter is: "I didn't attend to it as I thought it was not important, for I had done it a thousand times".
I come from an engineering background and had always been discriminating between the two. To reach an informed decision I need to know the two parameters unequivocally. Within my profession, allowing either of them masking the other is not considered good practice .
Civil aviation authorities follow the same dogma. Every instrumentation on the plane is in double. The essential flight parameters are derived from multiple units and by different processes. The pilots have a rigid routine to follow, regardless of what they may think of its importance. This is their recipe for minimizing accidents.
I didn't think it would hurt by getting the scan...Yes, Dr. Change is doing the procedures...
I think Dr Chang should decide what he needs.
If a color doppler is going to make you feel better somehow, relieve stress, teach you something, maybe even find something an MRI wouldn't, I think you should have one. Who is a doctor to say no, you can't have this test? There's no danger in having one, is there?
This reminds me of my urologist who told me that my cancer had revived, but when I wanted to check my PSA monthly he said no, you only need it every three months. Well, he's not the one with prostate cancer, he's not paying for the PSA test, and your doctor isn't paying for the doppler, so WTH do they care? If a test doesn't harm a patient and will make them feel better in some way, and maybe even help, what's the problem? Testing my PSA monthly is advisable, it could actually help, and I would think he would understand my position. He doesn't have prostate cancer, I do - and I found his attitude arrogant and inexplicable.
OK, an MRI is more sensitive than color Doppler. But is there a chance - because you're unique, because the MRI isn't working well (like the one that broke down in the middle of my scan), because of the innate workings of the machines - that the Doppler may find something the MRI didn't? Well, yes, there is - it's rudimentary statistics.
I fired my urologist - if he refuses this simple request, I've got no use for him. If Marks is as good as he's supposed to be, I probably wouldn't fire him, but I wouldn't take no for an answer either.
Tall Allen is correct consistently. Dr. Marks undoubtedly understands how insurers feel about these types of requests.
A typical systemic error in thinking:
The final and hence valued output from any imaging, is not the images by themselves, but the report that the radiologist has compiled. So, comparing equipment specifications alone, is worthless to say the least. The combo of equipment and human factor must be evaluated. Sorry, but if a production company uses the best cinematic equipment of today's, that alone does not lead to award winning pictures.
I have posted it before, but in a nutshell this is my own experience:
Prior to surgery I had 5 imaging sessions. 3 US, 1 CT and 1 MRI. Each one of them estimated the volume of my prostate. After surgery the actual volume of the my prostate was eventually measured. How about the prior estimates?
MRI and CT had grossly overestimated. 2/3 of the US also underestimated by large.
The closest to the actual value was the 3rd US.
I examined each and every image that I had. Did a numerical integration of the MRI axial sections* and asigned the overall error to 3 components: 1) Human error in reading the images. 2) Method's error, i.e. employment of the simplistic ellipsoidal shape's formula. 3) The residual to equipment's measurement accuracy.
I kept the fascinating info for last:
When I reviewed the image of the 3rd US I found out that if the radiologist had used his calculator to derive the volume from the image he would had landed in the region of the other two US.
Obviously, he did NOT. He probably judged it by the eye. He wrote in his report: "Prostate volume at the extremities of the normal range, 32ml".
Pathology found 33 gr and 35ml. MRI 59.465ml !!!
(*)There is a piece of software that does this automatically, but everyone I asked about it and in particular why they don't use it, I got almost the same answer: " The volume of the prostate is not important". Yet, they wrote it down in the report with 3 decimal points !!!
I think doctors should be more concerned with their patients rather than the insurers.
Tall Allen is indeed correct consistently. But he said nothing about insurers, and I doubt he cares about insurers compared to how much he obviously cares about people in general and individuals in particular. And doctors would be wise to emulate him in caring more about their patients than insurance companies.
If the doctor doesn't want to take the time to explain to the insurance company why a test is justified, that to me is an excellent reason to have a frank discussion with that doctor and learn exactly why he is refusing to order the test. If it's cost, that's none of the doctor's business. If it's necessity, well, again, if it's a safe test and it makes the patient feel better, what is the problem?
This doctor's response is more knee-jerk than thoughtful - he's going only by knowledge of the statistical efficacy of various tests, not by concern for his real-life patient, who is NOT a statistic.
As for the efficacy of tests - well, scans in particular are reliant on the person who reads and interprets them. Those scans are not infallible, and interpreters are even less so.
I see no legitimate reason why Ocman should not be able to have the test he thinks he needs, that has been proven to produce reliable results, and that is safe for the patient to have.
Keep looking. You will eventually find a doctor who will give you the (bad) advice you seem to want hear.
more a comment: when I was diagnosed in Feb 2017 - with bone mets. I was sent to a Urologist. So my first " gut " response to this man was - he seems very ' matter of fact" - abrupt ? has a very busy office - part of a larger group " Uro Partners ". So he demanded that all testing go through the company - same with prescriptions etc. He was not interested in accepting testing done my my PCP or HIV Dr - who do regular blood work. Was not willing to share info with other Drs even though they are part of the same medical group.
I did get a second opinion from an Oncologist - young guy at Uni of Chicago. Teacher - researcher - and always had time to listen to me. He said: " You need a Medical Oncologist on your team - whether it's me or someone else. I will be glad to provide care for you. Also, I will be glad to share info with all of your medical team."
I went back to the Urologist and relayed that info. Urologist said; " you do NOT need a medical oncologist and I am not going to share info with your other Drs and am not interested in reading their notes. "
Fired him - go to the Oncologist - who is taking excellent care of me. I definitely got the impression that the business was the priority and not Medical care. Also his office staff was - messy.
I have been under Dr Care for HIV - another cancer - and a variety of chronic issues for over 30 years - so I know a well run office and a listening Dr when I experience one.
I also wondered why a Urologist and not an Oncologist was dealing with my cancer from the beginning.
So there are my comments on this one.
BTW I really wish I had found this site 3 years ago - really appreciate reading and learning from others experiences and the support I have received.
Best to all
P
Ocman: CDUS would be used in a targeted-biopsy procedure and staging of the tumor. I had this with Dr Bahn in Ventura, and it was very useful in planning tx with my RO. Since you have already been staged, it wouldn't add much value, unless the MRI missed something. Here's an old study on CDUS vs MRI (1.5T).
onlinelibrary.wiley.com/doi...
Anyway, good luck with Dr Chang, he performed an excellent HDR-Brachy on myself last summer.
<timotur> glad to hear your procedures went well...did he use the spaceOAR hydrogel?
So who are some other good Urologists at UCLA?
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