Medical Tests: the more the better

I have two gripes with the medical profession. First, doctors should take more data not less. Also, medical professionals should recognize that most clinical trials assume that individuals are identical, which we know is untrue. I don’t direct these gripes at my doctors because I believe they are deeper thinkers than average and accommodate my eccentricities.

All tests have uncertainties and test results can also be affected by uncontrollable variables in people’s lives. As an example, physicians are reluctant to give the PSA (Prostate Specific Antigen) test to younger men under the pretense that anomalously high readings lead to unneeded tests (such as biopsies), which can have harmful side effects. But a paucity of data is the true culprit, where one bad reading in vacuum has little predictive value. The need for early testing is to set a baseline. It’s the change in PSA levels that should be of concern, not a single high reading.

The plot of my PSA data clearly shows a rise above the baseline starting in 2014. Such a slow rise could have many causes, such as an enlarged prostate – a common condition. In 2014, the data were too sparse to establish a trend, so my doctor suggested that we wait until the following year to see if the PSA levels had dropped. The level had not dropped the following year but was still below that magic value of 4, so we let it go another year. Once it hit 4, my doctor ordered an additional test that gives the ratio of free to bound PSA, which also came out too high, so he sent me to a specialist who ordered an MRI. Eventually this led to a biopsy, a diagnosis of prostate cancer and its removal in 2020. But this is an old story. 

See: https://unknownphysicist.blogspot.com/2020/06/i-was-relieved-i-had-cancer.html and https://unknownphysicist.blogspot.com/2021/01/can-major-surgery-cure-depression.html 

More recently, I got COVID while at a meeting in Seattle, then passed it along to my wife. My children had noticed that their resting heart rates had climbed when they had COVID last year. Since we all have Fitbits, I plotted the values for my wife and me, which appear in the plot here. The trends are remarkably similar.

During my travel days, presumably when I picked up the virus, my resting heat rate was at the baseline value of 47 beats per minute. The day after I returned, my resting heart rate began to rise and I tested positive for COVID on the second day after my return. Given that Omicron has a two-day incubation period, testing positive on the second day of my return is consistent with me being infected while traveling on trains and planes. My wife tested positive two days after I tested positive, consistent with me infecting her the night I returned. My resting heart rate at its peak was 53 BPS, which is 13% above my baseline, while my wife peaked at 17% above her baseline. Interestingly, the Fitbit records the average resting heart rate over the full day, and mine read 55 at its peak in the middle of the day before dropping to an average for the day of 53, so if I had used 55 as the peak, my increase too would have been 17% above the baseline. Here again, we can see that a simple measure of a common physiological metric provides useful health information, and used in combination with other tests could yield even better predictions of health risks that inform behavior. Having a nurse measuring your pulse once a year will only catch huge variation, which might miss important red flags. So, we need more testing!

Two family friends who I believe are both excellent physicians tell me that my metrics defy the conclusions of medical studies. My guess is that there are two factors involved. First, each human being has its own genetic makeup. There are many commonalities humans, such as infections making us sick and our immune system fighting back. But the details of how we each respond depend on our genetic programming. People like me have no problem with COVID, which I got in 2020 at a time when vaccines were not available, and the death rate was high. It’s genetic variability that gave me the strength to play ice hockey while infected during a time when others were on respirators and died.

Population studies take averages of metrics over people of varied genetic traits. If a certain diet is found to lead to a 12% decrease in mortality, it could be that 2/3 of the population experiences a 21% decrease in mortality while 1/3 of the population experiences a 6% increase in mortality. So, making recommendations based on an average value might help a majority of individuals, but could be harming a large minority of them. To take such effects into account, any large populations studies should include a breakdown by individual to determine if subgroups have adverse outcomes. Unfortunately, many studies do not have a large enough sample size for such fine-grained studies of the sort needed to get at the truth. In such cases, the studies are more than worthless to the unlucky minority.

Cancer treatments are an example where researchers and clinicians are now beginning to tailor treatments to an individual’s DNA, which results in much improved outcomes. One must ask about the ethics of choosing a medical treatment based on a population average when it is known that some treatments may not only lack efficacy but might do harm to the patient.

Another difficulty is ensuring that study participants adhere to the study’s parameters. For example, many studies use questionnaires to query participants about their habits. How many people on a self-proclaimed low carb diets cheat by eating a bit of sugar here and there. It’s only human nature to downplay our transgressions and exaggerate our virtues. While N=1 studies are unreliable for generalization to the population at large, they are useful to the important 1; the individual being tested.

In a past post, I described how eliminating fruit while keeping the rest of my diet fixed greatly reduced my blood glucose. (see: https://unknownphysicist.blogspot.com/2023/01/fruit-is-bad-for-you-at-least-it-is-for.html) Obviously, many people do well with fruit but not me. As an update to that study, I recently noticed that my blood glucose had drifted upwards during my bout with COVID. It never got into triple digits, but on average was elevated. Then I realized that I had been using lozenges to soothe my throat. They contain honey and sugars, so taking about a half dozen of them per day was enough to be noticeable. Within a few days of stopping, my blood glucose dropped.

For these reasons, I am an advocate for taking and analyzing more data. In aggregate, the data contains much more information than a yearly reading. Also, I believe that I’m more disciplined than the average survey taker, so I can trust my data to decide on a healthy lifestyle that suits my genetics. After my recent data with resting heart rate, I am motivated to cull my data in search of other interesting correlations that I can use to design new experiments. Until then, happy self-experimentation!

Hockey as a cure for COVID

Two years ago, I caught COVID classic. Five days later, not knowing that I was sick, I played ice hockey while wearing a mask just at the onset of peak symptoms. The next day I felt much better but got the PCR test anyway, learning 48 hours later that I was positive. Based on my personal experience, I am writing to inform your readers that vigorous exercise in cold air while wearing a mask cures the coronavirus. Disclaimer: the medical establishment warns against strenuous activity while infected with COVID.

I don’t care that scientists meticulously design studies and experiments to control for artifacts and bias. I don’t trust the experts at the CDC and other apolitical science-based government agencies who summarize the results based on a careful analysis of the aggregate data from the scientific literature. I don’t believe that reliable data should inform policy.

I trust personal experience above all else, so I know that playing ice hockey cured me of COVID.

Can Major Surgery Cure Depression?

The holidays are a good time to look back on our lives.  On this past Christmas eve, I was reading an article in the American Journal of Physics (AJP) on the topic of energy spectra for power-law potentials.  What a great coincidence that I had done this same calculation exactly a decade back, as I was reminded by a blog post from that time (see 2010 post).  I had not mentioned the details of the calculation in that post but was instead writing about how my wife Pat allowed me to isolate myself to work on this fun calculation while she and the rest of my family were preparing for our Ukrainian dinner.

At age 94, that would be my father’s last solo trip to Pullman, something I had expected at the time based on his cognitive decline.  Both our children were home for the holidays, waiting for the first visible star to appear, which would signal the time for our twelve-course Christmas Eve meal to begin -- a Ukrainian tradition that had been passed down through countless generations.

All morning, my father hovered over Pat in the kitchen to make sure that the cabbage was properly steamed, enough onions were sautéed for the butter topping and that the borsch had lots of garlic.  All the burners were on and the windows were painted in condensate that was crisscrossed by several rivulets that ended in miniature puddles on the windowsill.  Ukrainian Choral Christmas music blared over the speakers, drowning out the cooking sounds.  My father sang along with his rich operatic voice, with hands clasped behind him as he monitored the kitchen.  Our children were contacting old friends to plan for their yearly rendezvous at Ricos.  I was content in my calculations and secure in the presence of family.

My past posts consistently show the centrality of family and physics in my life.  Our families have grown -- both of our children with spouses and children of their own -- but I am now the father and the grandfather, taking the role of the patriarch.  My father briefly saw his first great grandchild (by Skype) just before he died in 2014.  Hopefully, I will see my own great grandchildren some day.

2020 was a year of illness and isolation.  I started the year by learning that I had prostate cancer.  My surgery coincided with the peak of COVID deaths in April (see link to the details).  It went well and the experience was a blip in the grand scheme of my life.  I kept busy writing papers (a couple which were accepted for publication in AJP and a massive review article that was accepted in the prestigious Advances in Optics and Photonics) and pondering new ideas, so my mind rarely wandered into the minefield of anxiety about my health.

My prostate surgery had other benefits.  I had been suffering with an undercurrent of depression since the passing of my father in December of 2014.  Though I had many reasons to be joyful since then, a deep-seeded darkness tugged at me, preventing me from feeling the unfettered happiness that was warranted by major events in my life.  This darkness lifted when I awoke from prostate surgery.  The experience reminded me of my mother’s depression years before she was diagnosed with cervical cancer.  Could it be that the human body signals the brain during a serious illness before other symptoms arise?  To investigate the plausibility of this hypothesis, I studied a plot of my Prostate Specific Antigen (PSA) test over time (see figure to the right).  Being measured as part of my yearly physical blood draw, my PSA data spans two decades.  In my younger years, the PSA data varied about the mean in a way that is characteristics of random noise.  But in 2014 (or perhaps as early as 2012), it started rising ever so slowly, following an exponential that a couple years ago pierced through to the level considered worrisome.  This proves nothing other than my depression being correlated with my father's death and the rise of my PSA.  But an intriguing correlation that my oncologist said he has independently observed...

My wife and I were isolated for most of 2020, but nevertheless we got COVID in November.  I traced

the probable location of my infection to the ice hockey rink, where I played masked with only 5 players. (The photo gives proof of us wearing masks -- but taken after I recovered from COVID).  Given the large separation between us, I was surprised that this was ground zero.  However, the  cold air and lingering breath droplets that it suspends, coupled with the heavy breathing associated with physical exertion no doubt made the ice a more dangerous place than I had expected.

We are fortunate that we had the mildest possible COVID symptoms and only for a short time.  I started feeling fatigue after playing ice hockey on a Sunday morning.  Most of the fatigue subsided after a 2-hour nap that afternoon after I had completed my weekend chores.  For the next couple days, I continued to feel mild fatigue, some achiness and had slight congestion that was comparable to what I normally experience from allergies.  I tested positive on the day after my symptoms appeared, and by Wednesday, I felt fine.  The only symptom that persisted for a couple weeks was the loss of the sense of smell, which returned gradually over time.

Overall, it was a good year, with the added benefit of the optimism I feel for 2021.

2021 has already started out well.  We visited my son, his wife and daughter on the other side of the country and also visited our daughter and her family.  Being immune to COVID (I tested positive for COVID antibodies) allows us to travel, so getting it was a net positive.  Also, I bought myself a nice Questar telescope (used on eBay), which I had coveted for decades, and plan to use it in our wilderness.  I will be teaching two graduate courses this spring, one of them a new prep (Thermodynamics), a topic that I am excited to revisit with the goal of deepening my understanding.  I am writing this post as I take a break from preparing my notes and doing the homework problems.

We will be using the thermodynamics textbook by Herb Callen, the professor that taught me the topic when I took his course at the University of Pennsylvania 40 years ago.  I recall the class being the worst in my graduate career – perhaps I was to blame.  But his book is fantastic, presenting the material clearly and resolving common points of confusion.  Working all the problems in the book consumes most of my time but doing so helps me to anticipate issues that students might have when learning the material.  And I am learning a lot through an enjoyable process of frustration followed by the satisfaction of success.

It is wonderful having a job that requires me to learn new things every day and a network of family and friends with whom I play and share my life.  Happy New Year!

 

I was relieved I had cancer

Synopsis

I was diagnosed with prostate cancer the first week of 2020 and my prostate was removed on April 21st.  I shared the news only with my immediate family and a couple of compatriots who coincidentally had had the same diagnosis.

That time between my diagnosis and surgery was filled with many memorable moments that made me forget about those rogue cells dividing within me.  It was not an intentional effort to look for diversions, I was just busy doing the things that I enjoy.   We visited our grandchildren for fun outings and hung out with friends;  A couple of my PhD students defended their PhDs; I did some of my own work in the lab with my own hands, interacted with my students on research projects, and developed new ideas for future research.  In addition, I wrote several papers and spent almost one day per week working on my cabin in the wilderness.  I enjoyed playing floor hockey and ice hockey -- ending the season as the highest-scoring player in the league.  I even squeezed in a ski trip with friends.

So, in heart and mind, I did not feel like someone with cancer.  I did not give myself that label.  The impending procedure was in the future akin to an upcoming tooth extraction – an unpleasant event, but because of the good prognosis, a relatively short period of recuperation and a wonderful life to return to afterwards.  I was not in denial; I just did not want to spend time discussing it as you might not care to talk about your upcoming dental visit or physical.  That would have been a distraction from all the fun I was having, especially in my work, pondering the beauty of physics.

I was tense over the wait, not at the dread of the surgery but by the possibility that it could be postponed.  Much can happen in four months, as it did.  COVID raged and accelerated, postponing elective surgeries.  I was lucky enough to have my surgery deemed a necessity due to the life-threatening nature of cancer.  What if my surgeon got ill?  What if he broke his wrist during his spring vacation?   I was vigilant in taking precautions from getting sick, not so much out of concern of getting COVID, but avoiding symptoms that would postpone my prostate’s date with a 6-clawed robot.

The surgical procedure and recovery put my life on pause for a few hours.  I was carted off to the operating theater a little before noon by the anesthesiologist, with whom I discussed the tastiness of Philly cheesesteaks.   I was extolling the virtues of fried onions bathed in Cheese Whiz as he placed the plastic mask over my nose and mouth.   An instant later I found myself in post-op at around 3:00pm, groggily lazing about with several other patients, some of them groaning.

On my way to surgery

The kind nurses gave me lots of saltine crackers and soda for the nausea, which soon subsided.  The catheter was a great convenience that allowed me to drink heavily without needing to get up to use the bathroom.  I fired up my iPad at 5:00pm (at about the time the morphine finally wore off) to answer work emails and to text family and friends (no visitors were allowed because of COVID), then walked almost a quarter of a mile around the hallways of our hospital wing by 7:00pm.  My roommate was a heavy snorer, keeping me awake most of the night so at 5:00am the day after my surgery, I took a three-quarter mile walk in the dark hallways, pushing my IV pole in front of me – the squeaky wheels grabbing the attention of nurses at their stations as I walked by.  By the third circuit, they smiled in my direction as I passed by.  I was discharged shortly after noon and was working at my computer at home by 3:00pm.

Getting in the car after being discharged

Most of you never noticed.  The day after I was discharged, I had a couple Zoom meetings.   The first several days after surgery we ran into several of you while taking a walk around Pullman.  A week later, just after the catheter was removed, some friends visited to drink beer and snack on our back deck to provide social distancing.

Just had my final test results a week ago, and things are looking great.  One needs to be clean for 5 years to be considered cured, but I will not be holding my breath.  Rather, I have already returned to the pleasures of life and my work without any thought as to what lies ahead not because I am actively fighting negative thoughts, but because the joys of thinking about physics and doing research, spending time with family and friends, and working on our cabin in the wilderness keep me occupied.

The Details

``You have cancer.”

I was relieved.

Early 2018, my PSA results alerted me to the possibility that I had prostate cancer.  My MRI showed a dark spot that the radiologist determined was likely cancer, a result that I got on my 60th birthday.  That meant a biopsy was needed, which turned out to be an intensely unpleasant experience because the local anesthetic did not take.  Each of the 12 spring-loaded needles bit through my prostate, gouging out a long thin cylinder of prostate tissue.   On the bright side, a week later I was told, “No cancer!”

I played floor hockey the night after my morning biopsy, ignoring the blood that was accumulating in places that I am too polite to describe.  I was more than annoyed at the graduate student who taunted me for not being as fast as usual – you know who you are.

About thirty percent of the time, all twelve cores of a standard biopsy miss the cancer, giving a false negative.  To avoid the trauma of a second biopsy, I was administered a genetic test, which starts with a vigorous prostate massage on a full bladder (mine was on Valentine’s day) to induce the appropriate secretions that are collected in a urine sample, which is a huge relief to provide.  The result: Low Risk!  Chance of cancer <2 again.="" br="" i="" nbsp="" relieved="" was="">
But my PSA continued to increase so another MRI was ordered, which showed the dark spot had noticeably grown over 16 months.  To make a long story short, an improbable sequence of events got me an appointment with a highly competent urologist in Spokane who specializes in oncology.  He looked at the MRI and immediately concluded that it was cancer, that it was localized and that it should be easy to treat.  “Of course the biopsy was negative,” he said, “because the cancer is in a place that normal biopsy needles don’t reach.”  He scheduled a 29-core biopsy to get plenty of samples and he would use the transperineal procedure, which would reach the suspicious region, but was invasive enough to require general anesthesia – fine by me!

I had the procedure early in the morning of December 31st, 2019, celebrated the new year with friends – who were unaware of the blood once again pooling in many places of my body.  We then visited our son and his wife and their new baby girl in North Carolina the rest of the first week of January.  On our return, we visited my daughter and her family then saw my oncologist for the results.

``You have Cancer,” he said, and gave the details.  I was relieved to finally have a definitive diagnosis.  Now the facts could be used to determine the best course of action, which ended up being a radical prostatectomy.  I am pretty much back to normal aside from the occasional pang of minor pain in my gut or the itch from one of the 6 incisions on my abdomen.

I am cleared to play hockey again.  Cannot wait to start, so watch out!