Users of smokeless tobacco product were found to have higher risk of death from prostate cancer

According to a new study, snus, a smokeless tobacco product, may increase a prostate cancer patient’s risk of death.

Some have suggested that because it lacks the combustive effects of smoking, that snus is a less a harmful alternative to smoking.

However, researchers found the men who used snus and had prostate cancer were at increased risk of premature death.

Pronounced as though it rhymes with “goose”, snus is used mainly in Sweden but is also available in the United States. Sold most often in a bag resembling a tea bag, users place the powdered tobacco product under the upper lip for extended periods.

The researchers investigating snus users, found that, compared with men who never used tobacco, those non-smokers who used snus had a 24 percent higher risk of death from prostate cancer during the study period. They also had a 19 percent higher risk of death from any cause.

The study found that for those non-smokers who used snus whose cancer had not spread; these patients were three times more likely to die from prostate cancer than those who never used tobacco.

The study co-author concluded that there is some evidence from animal studies that nicotine can promote cancer progression, and snus users have high blood levels of nicotine. Although snus is a smokeless product, users are still exposed to other carcinogens in tobacco.

The results of the study suggest that the health effects of smokeless tobacco products can be detrimental to men diagnosed with prostate cancer.

New research regarding prostate cancer prevention

Researchers continue to look for foods (or substances in them) that can help lower prostate cancer risk. Scientists have found some substances in tomatoes (lycopenes) and soybeans (isoflavones) that might help prevent prostate cancer. Studies are now looking at the possible effects of these compounds more closely.

Scientists are also trying to develop related compounds that are even more potent and might be used as dietary supplements. So far, most research suggests that a balanced diet including these foods as well as other fruits and vegetables is probably of greater benefit than taking these substances as dietary supplements.

One vitamin that may be important in prevention is vitamin D. Some studies have found that men with high levels of vitamin D seem to have a lower risk of developing the more lethal forms of prostate cancer. Overall though, studies have not found that vitamin D protects against prostate cancer.

Many people assume that vitamins and other natural substances are safe to take, but recent research has shown that high doses of some may be harmful, including those in supplements marketed specifically for prostate cancer. For example, one study found that men who take more than 7 multivitamin tablets per week may have an increased risk of developing advanced prostate cancer. Another study showed a higher risk of prostate cancer in men who had high blood levels of omega-3 fatty acids. Fish oil capsules, which some people take to help with their heart, contain large amounts of omega-3 fatty acids.

Some research has suggested that men who take a daily aspirin for a long time might have a lower risk of getting and dying from prostate cancer. Still, more research is needed to confirm this, and to confirm that any benefit outweighs potential risks, such as bleeding.

Scientists have also tested certain hormonal medicines called 5-alpha reductase inhibitors as a way of reducing prostate cancer risk

PSA Testing Differs Among Primary Care Doctors, Urologists

When it comes to prostate-specific antigen (PSA) testing, a new study reports that urologists are far more likely than primary care doctors to do perform these prostate cancer screenings.

The test is simple. blood sample is taken and sent to a laboratory to check for levels of a protein produced by cells of the prostate gland.

After the U.S. Preventative Services Task force recommended against routinely screening all men in 2011, PSA testing declined overall. New research shows that the decline in number of men tested was sharper among primary care doctors than urologists.

PSA testing decreased from 36 percent to 16 percent at primary care physician visits between 2010 and 2012. Researchers found that the decline in PSA testing was much smaller in urologist visits, dropping from 39 percent to 34 percent.

This discrepancy may reflect different perceptions of the benefits of the test among doctors, according to a study published online in JAMA Internal Medicine.

This much larger decline in PSA testing among primary care doctors could also stem from conflicting prostate cancer screening guidelines and differences in patients’ demographics or expectations, the study authors suggested.

The research team used the National Ambulatory Medical Care Survey to examine PSA testing one year before and one year after the task force recommendations were issued.

The study involved nearly 1,200 preventive office visits made by men aged 50 to 74 who were not diagnosed with cancer or any other prostate condition. Primary care doctors were seen in 1,100 of these visits. The others were examined by a urologist, a doctor who specializes in the urinary tract.

New Research Into The Prevention Of Prostate Cancer

Researchers continue to look for foods (or substances in them) that can help lower prostate cancer risk. Scientists have found some substances in tomatoes (lycopenes) and soybeans (isoflavones) that might help prevent prostate cancer. Studies are now looking at the possible effects of these compounds more closely. Scientists are also trying to develop related compounds that are even more potent and might be used as dietary supplements. So far, most research suggests that a balanced diet including these foods as well as other fruits and vegetables is of greater benefit than taking these substances as dietary supplements.

Some studies have suggested that certain vitamin and mineral supplements (such as vitamin E and selenium) might lower prostate cancer risk. But a large study of this issue, called the Selenium and Vitamin E Cancer Prevention Trial (SELECT), found that neither vitamin E nor selenium supplements lowered prostate cancer risk after daily use for about 5 years. In fact, men taking the vitamin E supplements were later found to have a slightly higher risk of prostate cancer.

Another vitamin that may be important is vitamin D. Some studies have found that men with high levels of vitamin D seem to have a lower risk of developing the more lethal forms of prostate cancer. Overall though, studies have not found that vitamin D protects against prostate cancer.
Many people assume that vitamins and other natural substances cause no harm, but recent research has shown that high doses may be harmful, including those in supplements marketed specifically for prostate cancer. For example, one study found that men who take more than 7 multivitamin tablets per week may have an increased risk of developing advanced prostate cancer. Another study showed a higher risk of prostate cancer in men who had high blood levels of omega-3 fatty acids. Fish oil capsules, which some people take to help with their heart, contain large amounts of omega-3 fatty acids.

Some research has suggested that men who take aspirin daily for a long time might have a lower risk of getting and dying from prostate cancer, but more research is needed to confirm this.
Scientists have also tested certain hormonal medicines called 5-alpha reductase inhibitors as a way of reducing prostate cancer risk.

Chemotherapy in combination with hormone therapy in advanced prostate cancer

A new study has concluded that chemotherapy at the start of hormone therapy can extend the lives of men with prostate cancer that has spread beyond the gland.

Over nearly 29 months of follow-up, men with advanced prostate cancer who received the combination therapy lived almost 14 months longer than men who received only hormone therapy (58 months versus 44 months), researchers said.

Men who have hormone-sensitive metastatic prostate cancer should consider speaking with their doctors about having this combination treatment to significantly prolong their survival. For 50 years, hormone therapy has been the standard care for these patients, but adding chemotherapy to hormone therapy may be worth doing because even though it’s not a cure, it could very well improve survival and quality of life.

The study was funded by the U.S. National Cancer Institute, and the report was published Aug. 5 online in the New England Journal of Medicine.

For the study, 790 men with prostate cancer, average age 63 were randomly assigned to have either chemotherapy plus hormone therapy or hormone therapy alone.

In addition to the survival benefit, men who received the combination of chemotherapy and hormone therapy saw their cancer remain dormant for more than 20 months before it began to progress, compared with close to 12 months among those who only received hormone therapy, researchers found.

The side effects of the chemotherapy were mild, in general. Fatigue, low white blood cell count and infection were the most common side effects, the study said.

One of the criteria for the treatment is that patients should be able to handle the chemotherapy. If they have other conditions such as liver or kidney disease, they should not be getting chemotherapy. In the study, the greatest benefit was seen in men who had four or more tumors outside the prostate.

Other studies have confirmed these findings.

Common Myths About Prostate Cancer

Myth Number One: Everyone that gets prostate cancer will die of the disease.

Fact: Checking for prostate cancer is incredibly important, but patients with prostate cancer are likely live to an old age and/or die of some other cause. Detecting prostate cancer early and working with expert doctors like Dr. Gaertner and Dr. Knoedler on a treatment plan is crucial.

Myth Number Two: If you have high PSA score that you definitely have prostate cancer.

Fact: Some high PSA scores can be due to an inflammation in the prostate or an enlarged prostate. The PSA score is a guideline to help Dr. Knoedler or Dr. Gaertner decide if you need more tests to check for prostate cancer. The doctors are interested in your PSA score over time. If it continues to increase it could be a sign of a problem. If it decreases after cancer treatment that is great.

Patients at Metro Urology now have access to UroNav, which is an MRI assisted, ultrasound-guided biopsy technique which provides a new level of accuracy to the detection of prostate cancer. Because it can detect prostate cancers in hard to find areas of the prostate, UroNav can reduce the need for multiple biopsies and find cancers in men with previous negative biopsies but high/rising PSA scores.

UroNav is a new high tech approach to the diagnosis of prostate cancer and Metro Urology is the only private urology practice in the Twin Cities to have this technology. UroNav testing has already found aggressive prostate cancers in men with previous negative biopsies.

Myth Three: Prostate cancer surgery will ultimately end your sex life and cause urine leakage.

Fact; Sex Life: Using the highest tech equipment to perform robotic surgery with the da Vinci system, Dr. Knoedler and Dr. Gaertner work to spare the nerves that help trigger erections. Because of their combined talents they have a great success rate with patients that are able to have an erection strong enough for sex again. Depending on the patient, recovery can take from 4 to 24 months, maybe longer and in general younger men usually recover sooner.

Fact; Urine Leakage: While urine leakage is common immediately after surgery it is almost always temporary. Dr. Gaertner and Dr. Knoedler have an excellent success rate in this area and within a year, approximately 95% of men have as much bladder control as they did before surgery.

Myth Four: The only men at risk of prostate cancer are elderly.

Fact: Although prostate cancer is fairly rare for men under 40 some men should be tested earlier. Age is not the only risk factor for the disease. Others include:

  • Family history. For patients whose father or brother had prostate cancer, their own risk doubles or triples. The more relatives a patient has with the disease, the greater their chances of getting it.
  • Race. African-American men have a higher risk of prostate cancer than men of other races, the reason is still unknown.

Talk to Dr. Gaertner and Dr. Knoedler about when you should start PSA testing.

Myth Five: Patients must have all prostate cancers treated.

Fact: In some cases patients and their doctors may decide not to treat prostate cancer. Reasons include:

  • If the cancer is at an early stage and is growing very slowly.
  • If the patient is elderly and has other illnesses. In cases like these the treatment for prostate cancer may not prolong life and may actually complicate care for other health problems.

In such cases Dr. Gaertner and Dr. Knoedler may suggest “active surveillance.” This means that they will regularly check the patient to make sure the cancer does not worsen. If the situation changes, the doctors may decide to start treatment.

15 Cancer Symptoms Men Tend to Ignore

One of the best ways to fight cancer is to catch it in the early stages, when it’s more treatable. The problem is that the warning signs for many kinds of cancer can seem pretty mild.

Take a look at these 15 signs and symptoms. Some are linked more strongly to cancer than others, but all are worth knowing about — and even talking over with your doctor.

1. Problems When You Pee

Many men have some problems peeing as they get older, like:

  • A need to pee more often, especially at night
  • Dribbling, leaking, or an urgent need to go
  • Trouble starting to pee, or a weak stream

An enlarged prostate gland usually causes these symptoms, but so can prostate cancer. See your doctor to check on the cause of the problem. He’ll give you an exam to look for an enlarged prostate, and he may talk to you about a blood test (called a PSA test) for prostate cancer.

2. Changes in Your Testicles

If you notice a lump, heaviness, or any other change in your testicle, never delay having it looked at. Unlike prostate cancer, which grows slowly, testicular cancer can take off overnight. Your doctor will look for any problems with a physical exam, blood tests, and an ultrasound of your scrotum.

3. Blood in Your Pee or Stool

These can be among the first signs of cancer of the bladder, kidneys, or colon. It’s a good idea to see your doctor for any bleeding that’s not normal, even if you don’t have other symptoms. Although you’re more likely to have a problem that’s not cancer, like hemorrhoids or a urinary infection, it’s important to find and treat the cause.

4. Skin Changes

When you notice a change in the size, shape, or color of a mole or other spot on your skin, see your doctor as soon as you can. Spots that are new or look different are top signs of skin cancer. You’ll need an exam and perhaps a biopsy, which means doctors remove a small piece of tissue for testing. With skin cancer, you don’t want to wait.

5. Changes in Lymph Nodes

Swollen lymph nodes, small bean-shaped glands found in your neck, armpits, and other places, often signal that something’s going on in your body. Usually, they mean your immune system is fighting a sore throat or cold, but certain cancers also can make them change. Have your doctor check any swelling that doesn’t get better in 2 to 4 weeks.

6. Trouble Swallowing

Some people have trouble swallowing from time to time. But if your problems don’t go away and you’re also losing weight or vomiting, your doctor may want to check you for throat or stomach cancer. He’ll start with a throat exam and barium X-ray. During a barium test, you drink a special liquid that makes your throat stand out on the X-ray.

7. Heartburn

You can take care of most cases of heartburn with changes to your diet, drinking habits, and stress levels. If that doesn’t help, ask your doctor to look into your symptoms. Heartburn that doesn’t go away or gets worse could mean stomach or throat cancer.

8. Mouth Changes

If you smoke or chew tobacco, you have a higher risk of mouth cancer. Keep an eye out for white or red patches inside your mouth or on your lips. Talk to your doctor or dentist about tests and treatments.

9. Weight Loss Without Trying

Pants fitting a little looser? If you haven’t changed your diet or exercise habits, it could mean that stress or a thyroid problem is taking a toll. But losing 10 pounds or more without trying isn’t normal. Although most unintended weight loss is not cancer, it’s one of the signs of cancer of the pancreas, stomach, or lungs. Your doctor can find out more with blood tests and tools that make detailed pictures of the inside of your body, like a CT or PET scan.

10. Fever

A fever is usually not a bad thing — it means your body is fighting an infection. But one that won’t go away and doesn’t have an explanation could signal leukemia or another blood cancer. Your doctor should take your medical history and give you a physical exam to check on the cause.

11. Breast Changes

Men tend to ignore breast lumps because breast cancer isn’t on their radar. But 1% of all breast cancers occur in men, although they’re usually diagnosed much later. Don’t take any chances. If you find a lump, tell your doctor and have it checked.

12. Fatigue

Many types of cancer cause a bone-deep tiredness that never gets better, no matter how much rest you get. It’s different from the exhaustion you feel after a hectic week or a lot of activity. If fatigue is affecting your daily life, talk to your doctor who can help you find the cause and let you know if there are ways to treat it.

13. Cough

In nonsmokers, a nagging cough is almost never cancer. Most go away after 3 to 4 weeks. If yours doesn’t, and you’re short of breath or cough up blood, don’t delay a visit to your doctor, especially if you smoke. A cough is the most common sign of lung cancer. Your doctor can test mucus from your lungs to see if you have an infection. He may also give you a chest X-ray to check for another problem.

14. Pain

Cancer doesn’t cause most aches and pains, but if you’re hurting for more than a month, don’t just grin and bear it. Ongoing pain can be a signal of many types of cancer, especially those that have spread.

15. Belly Pain and Depression

It’s rare, but depression along with stomach pain can be a sign of cancer of the pancreas. Should you worry? Not unless this cancer runs in your family. Then you need to see your doctor.

Kegel Exercise for Men Post-Prostate Surgery

When you have prostate cancer surgery or radiation therapy the muscles that help you control your urine flow may be weakened. When this happens you may have incontinence. Incontinence is when you leak or pass urine when you do not want to. This is a very common side effect or unwanted change of prostate cancer treatment. The good news is that there is a simple exercise, called a Kegel (Keygul) exercise which you can do to help strengthen your muscles. This exercise will help you have more control over your urine flow after your prostate cancer treatment. In this article you will learn:

  • What a Kegel exercise is
  • Why you should do Kegel exercises
  • How to find your pelvic floor muscles
  • How often you should do your Kegel exercises

It is important for you to think about and plan how you will take care of yourself before and after your prostate cancer treatment so that you can keep doing as many of your normal activities as possible.

What Are Pelvic Floor Muscles?

Your pelvic floor muscles are a network of muscles that support your bladder and help you control your urine flow. There are three pelvic muscles:

  1. The bladder. Your bladder is a muscle shaped like a balloon and holds your urine.
  2. The sphincter muscles. These muscles help you open and close your urethra, the tube that drains urine from your bladder. And,
  3. The pelvic floor muscle [also known as the pubococcygeus (pu-bo-kak-sije- us) or PC muscle] supports your bladder and rectum and helps control your urine flow.

What are Kegel Exercises?

Kegel exercises are easy exercises you can do before and after your prostate cancer treatment to help strengthen your pelvic floor muscles. These muscles help control your urine flow. Kegel exercises are one of the most effective ways of controlling incontinence without medication or surgery.

Why Should I Do Kegel Exercises?

The prostate is a gland, about the size of a walnut, located under the bladder surrounding the upper part of the urethra. The urethra is a tube that carries urine through the penis to the outside of the body. There are many muscles that surround the prostate gland. These muscles may be weakened during your prostate cancer treatment. This may cause you to have urine leakage also known as incontinence. Building up the strength in your pelvic floor muscles can help you gain better control of your bladder and urine flow. Remember, that just as it takes time to build your biceps and strengthen any other muscle in your body, it takes time to strengthen muscles in your pelvic floor.

How Do I Find My Pelvic Floor Muscles?

In order to help strengthen you pelvic floor muscles, it is important that you take time to make sure you are exercising the right muscles. It may take you several tries to find your pelvic muscles. So, take your time.

There are several ways that you can find your pelvic floor muscles. One way is to:

Try to stop and start your urine stream while you stand at your toilet to urinate (pee). Try to do this two or three times.

Another way to find your pelvic floor muscles is to:

  1. Imagine that someone walks in to your bathroom while you are urinating (peeing) and you need to stop your urine flow.
  2. Try to stop your urine flow.

The muscles you use to stop your urine flow are your pelvic floor muscles. These are the muscles you want to strengthen before and after your prostate cancer treatment.

How Do I Do A Kegel Exercise?

Now that you have located your pelvic floor muscles, you can exercise them even when you do not have to urinate by following these simple steps:

  1. Tighten and hold your pelvic floor muscles for five seconds (count 1 one thousand, 2 one thousand, 3 one thousand, 4 one thousand, 5 one thousand).
  2. Relax your pelvic muscles. You have just done one Kegel exercise. You should plan to do 10 to 20 Kegel exercises three to four times each day.

Another way to tighten your pelvic floor muscles is to:

  1. Squeeze the muscles in your anus (like you are holding a bowel movement).
  2. Relax your pelvic floor muscles after each attempt.
  3. Repeat this exercise 10 to 20 times.

When you do your Kegel exercises, remember

  • Do not hold your breath.
  • Do not push down. Squeeze your muscles together tightly and imagine that you are trying to lift this muscle up.
  • Do not tighten the muscles in your stomach, buttocks, or thighs.
  • Relax your pelvic floor muscles between each squeeze.

How Often Should I Do My Kegel Exercises?

When you first start doing your Kegel exercises, you may not be able to repeat the exercise 10 to 20 times. This is ok. It is much better for you to do fewer Kegel exercises that make your pelvic floor muscles stronger, than to do more exercises that do not work the muscle in the right way. As you get better at doing your Kegel exercises, slowly increase the number of times you repeat the exercise until you reach 20. Your goal should be to do 20 Kegel exercises three to four times each day.

The great thing about Kegel exercises is that you can do them anytime you want to do them. No one can tell that you are doing these exercises. You do not need any special equipment to do Kegel exercises. You can do your Kegel exercises before you get up in the morning, at lunchtime, at suppertime, and at bedtime. You can do them while you are watching TV or reading. Some men put notes on their refrigerator or on their bathroom mirror to remind them to do their Kegel exercises. The more you do them, the stronger your pelvic floor muscles will become.

When Should I Do The Kegel Exercises?

It can take six weeks or longer to strengthen your pelvic floor muscles so it is best to start doing your Kegel exercises before you have prostate cancer treatment. This will help you become better at doing the Kegel exercises and strengthen your pelvic floor muscles before your treatment starts. Remember, your pelvic floor muscles are like any other muscle in your body. It takes regular exercise and time to strengthen them.

Can I do Kegel Exercises If I Have A Catheter?

A catheter is a thin rubber tube placed in your body to drain urine from your bladder out through your penis. Do not do any Kegel exercises if you have a catheter in your penis.

Start doing your Kegel exercises according to the instructions above as soon as the catheter is taken out of your penis. After your catheter is removed you may experience some urine leakage (incontinence) when you stand up, cough, sneeze, laugh, or lift something. You will probably need to use incontinence pads for a while. However, doing Kegel exercises may help you control your urine flow sooner. If you have urine leakage when you stand up, cough, sneeze, laugh, or lift something, try doing a Kegel exercise. This may keep you from leaking urine.

Will My Urine Leakage Stop if I Do The Kegel Exercises?

Most men gain control of their urine leakage (incontinence) within nine to 12 months after their surgery. Studies with men show that Kegel exercises help lessen urine leakage. However, each man’s healing time is different.

Do not become discouraged if you have urine leakage. If you do your Kegel exercises on a daily basis, you can expect to see some results. You may have a great improvement or you may help keep your urine leakage from getting worse. You will need to continue doing your Kegel exercises each day so that your pelvic floor muscles stay strong.

If you have any questions or concerns about urine leakage (incontinence), how to do a Kegel exercise, or if you would like to know about other things that may help with urine leakage, please talk to Dr. Gaertner or Dr. Knoedler.

Top ten things you should know about PSA testing for prostate cancer

The current controversy over PSA testing is actually not about whether we should detect prostate cancer, but whether all men who receive treatment actually need treatment. Because prostate cancer is slow growing not all men need treatment; some men can simply have their cancers monitored to see if the cancer grows (called active surveillance).

We advocate for patients who choose to monitor their cancers while also being strong in our advice to patients who may be reluctant to treat their cancer when we feel that a man should have treatment.

It is important to have a thorough discussion of the risks and benefits of prostate cancer screening with your primary care physician and urologist so that you can make a decision that is right for you.

Our hope is that this article will help you understand the issue and make informed decisions about your health care.

1. What is a PSA test? A PSA test is a blood test that is used to detect prostate cancer. PSA stands for Prostate Specific Antigen, a protein made in the prostate that leaks into the blood stream and can be detected. An elevated PSA may indicate you have prostate cancer.

Prostate cancer is detected in men with a combination of two tests – a manual exam of the prostate (digital rectal exam or DRE) and the PSA blood test. PSA testing has been clearly shown to help detect and treat prostate cancer early, before it spreads. A man who is screened for prostate cancer has less chance of developing incurable prostate cancer and is less likely to die from prostate cancer.

2. What is a normal PSA? There is no such thing as “normal” when it comes to PSA. Cancer is rarely found in men with PSA values less than 1. The higher the PSA, the higher the chance that a person has cancer. It is also very important to follow the trend in the PSA value (is it climbing? how fast?).

3. Does an Abnormal PSA test mean I have prostate cancer? No. In fact most high PSA tests do not mean a man has prostate cancer. Many men with elevated numbers never do get cancer even though they are at higher risk.

4. When should I get a PSA test? We recommend that a baseline serum PSA level be obtained in men in their 40s who have made an informed decision to pursue early detection of prostate cancer.

5. How often should I get a PSA? We recommend yearly testing for men age 50 and over who have at least a 10 year life expectancy. Men who have elevated PSA levels are followed more frequently.

6. If my PSA is normal, do I still need a prostate exam? Yes. We find many prostate cancers by physical exam that do not raise the PSA level. The cancer will make the prostate feel larger or firm in the area where the cancer is.

7. What PSA is too high? At Metro Urology we believe that a PSA should be 2.5 or less for men under 60, and less than 4.0 for men over 60. But the trend of the PSA value is also important. A rapidly rising PSA could be concerning, even if the number is still less than 2.5 or 4.0.

8. What happens if my PSA is too high? A PSA test that is too high requires a discussion with one of our physicians at Metro Urology to discuss your individual risk of prostate cancer. We can help you make the decision regarding further evaluation. Most men will be advised to have a prostate biopsy to determine if their prostate contains cancer.

9. What if my PSA is high but my prostate feels “normal”? This is very common. Most cancers are found early using the PSA test, before they grow out of the prostate and spread (called metastasis). Your physician may still recommend a biopsy because, if cancer is found, it is usually very treatable.

10. I have heard PSA testing is not accurate. Do all doctors agree on PSA testing? Recently, several prominent medical organizations have changed their recommendations regarding whether or not men should undergo prostate cancer screening. These conflicting reports lead to significant patient confusion.

Oncotype Prostate Assay

Patients with newly diagnosed low-risk prostate cancer—and their urologists—need to know the aggressiveness of their tumor. The Oncotype DX Prostate Cancer Assay can help. This genomic test performed on a patient’s needle biopsy provides essential insight into the underlying biology of that patient’s prostate cancer. The result is reported as the Genomic Prostate Score or GPS, and provides a more precise, accurate, and individualized risk assessment that can help a patient and his urologist make a confident choice between active surveillance and immediate treatment.
Visit http://prostate-cancer.oncotypedx.com/ for more information on test.