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PSA Testing Revisited

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

The United States Preventive Services Task Force announced in its final recommendation Monday that healthy men (at any age) should no longer get screened for prostate cancer with a PSA test because a resulting diagnosis may do more harm than good. While this forum has discussed this issue in some detail in the recent past this final recommendation by the USPSTF strikes me as singularly obtuse in its logic and, in my opinion, has squandered an opportunity to influence how the results of this test should be dealt with my physicians and patients.

Instead of working to change the procedures and improve the way this test is interpreted the task force prefers to shut down testing altogether because some doctors apparently use these results as a business development tool to seduce naive patients into receiving unnecessary treatment. In fact, if you were to read Dr. Virginia Moyer’s op-ed yesterday in USA Today you could easily believe that the actual PSA test itself was the instrument that caused damage. (See http://www.usatoday.com/news/opinion/story/2012-05-22/Preventive-Services-Task-Force/55145238/1) Our own Dr. Otis Brawley (not on the task force) who is the chief medical officer and scientist at ACS (the sponsor of our forum) wrote a op-ed on CNN on Monday indicating that more than a million men in the United States have been treated unnecessarily and been done harm as a result of the test. Other task force panel members have made public statements and appeared on various talk shows castigating the PSA test.

It is interesting to note that none of the present task force members are practicing oncologists or specialize in prostate cancer. While that qualification may not be necessary to draw conclusions from analyses of various studies it seems to me that the force of the recommendation lacks credibility. Dr. Moyer, the chairman of the task force for example, is a pediatrician. Other board members are nurses, public health specialists, community health advocates, and so forth.

The American Urological Association (an organization of doctors who actually specialize in prostate cancer) were outraged by the task force recommendation and issued a statement from their annual meeting in Atlanta that when properly interpreted the PSA test is a valuable tool in diagnosing, staging, and eventual treatment of prostate cancer (http://www.auanet.org/content/media/USPSTF_AUA_Response.pdf)

Certainly many men have been over treated for prostate cancer. We read of men in their 80s receiving surgery for low risk cancer, and most of us have heard our diagnosing physicians tell us that surgery can “get it out of you.” Many men do suffer from incontinence and ED as a result of various treatments that may not have been necessary. Despite this, in my opinion, it is not the PSA test that causes these results but an ill-informed patient at the hands of doctors who too often seem to put the economics of prostate cancer ahead of patient welfare and quality of life. The focus of the task force should have been, in my lay opinion, directed at family physicians and urologists who push for biopsies at almost any PSA reading instead of putting the PSA test in a comprehensive context with other physical symptoms, DRE results, family history, a PSA history, whether or not BPH is present, the potential for a UTI, and reminding the patient to avoid sexual relations for a few days before the blood draw. GPs tell us to avoid eating before having our blood drawn for blood sugar levels at our annual physicals but they never seem to tell us to avoid sex before the blood draw as well. (Sexual release within 48 hours of a PSA test will cause an abnormally high PSA reading).

At the end of the day I don’t think the USPFTF recommendations will amount to much. You may recall similar outrage at this committee’s recommendation about mammograms a few years ago and their recommendations for women at certain ages to avoid the test have been largely ignored. Immediately after the task force made its findings public, the Obama administration released a statement that Medicare would continue to cover the cost of the PSA test. If Medicare continues to pay (and I suspect most insurance companies will follow this standard as well) doctors will continue to do the test. Men do need to inform themselves about what the PSA test means to them and several other related factors but the task force avoided addressing these issues so nothing much will happen. A wasted opportunity all around.

K

ralph.townsend1's picture
ralph.townsend1
Posts: 352
Joined: Feb 2012

I think back on my primary Doctor in 2000 said, I'm going to test you every year for prostate cancer by testing your PSA. For the next 8 years the Psa 0.0 until Aug 2008 the psa comes back at 6.8,and Gleason score 4+5.

If I had not, by 2010 I would be in a condition that would????

Prostate Cancer only Kills about 30,000 in the US a year. There is another 300,000 that get damage by this cancer each year.

Then there is the ones that die from bone, lung, liver, and brain cancer that is associated with prostate cancer that never gets connected with PC.

starr15
Posts: 31
Joined: Oct 2011

The most helpful information for patients is in the AUA 2009 best practice statement regarding PSA testing. In it in FIGURE 2, data from the PCPT nicely shows the risk of biopsy detectable prostate cancer for PSA levels below 4 in men 55 and over. For example if your PSA is between 1 and 2, there is about a 17% chance of a biopsy detecting prostate cancer. Of those cancers, about 12 % will be Gleason 7 or higher. Clearly, PSA levels are a risk spectrum.
Wish we had a better screening test, right now, but we do not have it. Clearly, we need to be able to determine with much greater certainty which biopsy detected cancers will cause morbidity and mortality and which will not. We also need a reliable way to image the prostate and do targeted biopsies. One day, we will. Unfortunately, we are stuck in an era of insufficient scientific knowledge.
Donate to prostate cancer research.

http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf

rch
Posts: 79
Joined: Nov 2011

Ralph Townsend
I totally agree with you on annual PSA testing , but clarify for me your PSA history. You said your PSAs were 0.0 for 8 yrs ( I think you meant close to zero,not Zero), and then it suddenly jumped to 6.8 in 2008 with GS 4+5. Generally PSA testing is coupled with DRE. Did you have annual DREs ? It's not too uncommon to have a normal PSA with an abnormal DRE and a high GS.

ralph.townsend1's picture
ralph.townsend1
Posts: 352
Joined: Feb 2012

About every other year I got DRE. They were normal, the PSA was about 0.01 or 0.06, it was always close to "0". My PSA is low right now at 0.2 and January it was only 2.6. The Medicine Zytiga is keeping it down. I go back to MD Anderson for ct scan, bone scan in July to check out my little tumor's and see if there is any more of them.

Zytiga makes them very small and lonely. I hope!

Having low PSA is not uncommon with a high Gleason score. A PSA of 6.8 or 2.6 is not a high score, But the Gleason score 4+5 7 out of 12 sample and 2 other's were 3+4 which is not good. That little jump in my PSA was enough to alarm my doctor, Thank God!

hunter49
Posts: 201
Joined: Oct 2011

I was as healthy as an ox, not one sign of a problem with my prostate and normal DRE. My PSA jumped and after surgery I was a 4+3. Maybe I am wrong in feeling this way but that test saved my life. The issue is not the test but wht is done with the results and treatment if there is cancer. Again the real problem is not being addressed.

hopeful and opt...
Posts: 1304
Joined: Apr 2009

Resulting from this published recommendation there will be men who will not get a PSA screening test, and will be diagnosed with advanced cancers instead of early stage disease. There will an increase in suffering and death. Courts of law will not be able to hold doctors who do not screen accountable for these adverse conditions(since this is a published recommendation).

I wonder how much of this report is really focused on cost savings and not medical care advantages? I wonder if older men are expendable.

Swingshiftworker
Posts: 633
Joined: Mar 2010

FWIW, I don't think this "recommendation" will have any significant effect on PSA screenings for PCa because:

1) it doesn't make any common sense -- the problem is with the treatments NOT the screening,

2) it is not being made by a recognized professional urology/cancer specialty group and

3) PSA screenings bring too much money into the coffers of the labs/hospitals that run them (I just got a statement of charges (insured) for my last PSA test and it cost $306).

prezmic
Posts: 36
Joined: Jul 2011

Unfortunately with the move towards socialized medicine in the US, we will see more of this in the future. The government wants these types of reports so that they can use them to determine what will be covered. It is already happening in the UK.

http://www.guardian.co.uk/commentisfree/2012/mar/26/cancer-older-people-britain-care

This will not happen in the near future - but it will develop into a "means test" for medical care. The "means" will be determined by your age and the cost of keeping you alive. The gubment wins if you die early - savings in medical costs and social security. You've lived your life - bad luck and poor lifestyle choices will determine your fate.

laserlight's picture
laserlight
Posts: 165
Joined: May 2012

Today is Sunday morning, Fox news has their morning show on with the 2 doctors. They have just spoken out about the PSA testing and called this study very bad. They came out and have made comment that every male above 40 needs their PSA checked. My doctor started to check mine arount the age of 52 for about 8 years my score was at the .80 range. Nov of 2010 the score jumped to 1.25. My doctor sent me the Urologist, he performed the exam and tested again for PSA, again it jumped to 2.25 this was within about a 6 week time frame. This caused the urologist to schedule biopsy, results were stage t2c all 18 samples had cancer between 40 to 60 percent. I had no symptoms it was a simple psa blood screen that flagged the doctor. These panels that make ill informed comments really need to be called out. All they are thinking about is money. This PSA test is a simple life saving screening. Now the PSA score can vary, but it is a flag to the doctor that something is wrong. For me I am thankfull that my cancer was discovered and treated. I doubt that this panel has had to deal with the diagnosis of cancer in their own lifes, everybody that has gone thur or are going this knows how difficult this is, there is an old saying walk a mile in my shoes. Prostate cancer is bad and the side effects are difficult, but the thing to remember is that this is cancer we all have started down the road of a real life changing event. All I can say is ignore the Panel and let them keep their heads in the sand. I am thankfull for the PSA test

rch
Posts: 79
Joined: Nov 2011

PSA COUPLED WITH DRE ( a few days apart) should be an integral part of an annual physical and should be offered to every male over the age of 50, or 40 if high risk group or 10 yrs prior to the dx of PCa in a first degree relative. However, often times, people 'just get a PSA' without offering themselves for a DRE. This is just playing with numbers and serves very little purpose of PCa screening. Then there is also the question of Providers' expertise with the DRE ;how experienced is the Provider (and how long his/her fingers are !!). There is a great deal of subjectivity with DREs and that when coupled with PSA variablity not too uncommonly delays the diagnosis of advanced PCa. IMHO, one must obtain a second opinion on a DRE just as you would on a Biopsy specimen.

VascodaGama's picture
VascodaGama
Posts: 1543
Joined: Nov 2010

Swing

The laboratory doing your PSA test is “swindling” your insurer.
US$306 is just too much for a simple test using an ultra sensitive assay that costs 10 bucks.
How can it be so expensive?
In continental Europe the average charge is €40 (US$53) (€32 in Portugal). Your reference to the cost charged in USA is new to me and it wouldn’t surprise me now if USPSTF had that in mind in their conclusions. I hope that EU health care social systems do not follow American recommendations.

This thread is a continuation of a previous one (http://csn.cancer.org/node/227836) where many participated with their views. I sustain my opinion but would add your comment with regards to costs.

VG

prezmic
Posts: 36
Joined: Jul 2011

I just looked at the last insurance statement for PSA and DRE test.

PSA
- Laboratory charge: 107
- Network discount: 97.23
- Paid by plan: 9.77

Seems to be a reasonable charge for test compared to 306, but the reality is they will accept a much lower rate.

DRE
- Charge: 12
- Paid: 12

I have to laugh that a finger in my butt is only 12 dollars. Even a streetwalker would charge more.

Swingshiftworker
Posts: 633
Joined: Mar 2010

The lab is at the UCSF Medical Center & the insurer is Blue Shield of California.

The $306 is the amount on the statement that was sent to me but it may or may not be the amount they actually charged Blue Shield or that Blue Shied was willing to pay UCSF.

Doesn't matter to me what UCSF charged or got paid by Blue Shield because I didn't have to pay it directly; only indirectly through my insurance premiums which are minimal.

But, FWIW & IMHO, medical costs in the US are way out of line and you can always get similar health care or treatment in other countries for much less than is charged here.

BTW, when I first contacted UCSF for CyberKnife treatment, I was told that the insured cost would be $70,000 but that, if I had to pay for it out of pocket, they would "only" charge me $60,000 (15% less).

I assume they'd still be making money on it either way, so there apparently is a lot of "room" to make adjustments in the cost of medical care as charged (at least) by UCSF.

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