PSA Test Not Needed?? CNN posted today

guards

KathyLQ said:

What about the Gleason Score? And DNA ploidy?
I asked my boyfriend for more specifics. He is 71, he has a Gleason Score of 7, and one biopsy core was 15%, and and 2nd biopsy core was 5%. At this current time, he is leaning towards the robotic surgery. BF is very active, not overweight, walks 5 miles regularly, rides a bike 5-10 miles regularly. Has relatives that have lived into their 90's.

I found this article at the Prostate Cancer Research Institute interesting: http://www.prostate-cancer.org/pcricms/node/165. Titled: "The Gleason Score: A Significant Biologic Manifestation of Prostate Cancer Aggressiveness On Biopsy"

It mentions a DNA analysis, called "DNA ploidy". Is this being done?

Comments?

Watchful waiting
Kathy have him consider this seriously. I played golf. rode my bike, traveled about 15000 miles a yr on my motor cycle, and had sex with my wife, Thank to treatment and incontinance it all went away. You don't play golf while your pissing your depends. You can't ride a even a recumbent bike unless you can change pads somewhere on the bike path because its like a pump and fills them fast, You cant even make iit through a trip shopping at the grocery store with your wife unless they have a restroom handy so you can change,
So likey will be a very dramitic change somewhere down the road . If some one had explained the survival rate and conquences of treatment on a understandable form ? Would I have chosen differently knowing what I know today YOU BETCHA, 10-15 YEARS of a real life versus the $%^%%#$@ And the life I currently have. Ill take my shot at 80 and a normal life.

Kongo

jerrylh said:

your comments
Hi Kathy

First of all regards your boyfriend, no he would wait until he is 85 and never need anything done for his prostate cancer. Be aware that at age 85 95% of ALL men have prostate cancer and that 100% of all males age 90 have prostate cancer. Remember that only 2.5 to 3.0% of men with prostate cancer will die from their disease. And that death rate is the same even in countries where there is no screening. Remember, Kathy, these are recommendations for healthy males, not for males with blood in their urine for example.

The reaction of most of the readers here is not surprising. in the 1950s and 1960s everyone was getting screening chest x-rays to detect early lung cancer. The studies revealed that we were not saving lives, but the screening continued for another 10 years until it finally died out.

Jerry

Question
Jerry,

Are you a prostate cancer survivor? If so, how were you diagnosed? Most men, in my opinion, are grateful for the information the PSA test provided. They may well be unhappy with the results of their treatment but I am sure most men want to know if their PSA test even remotely suggests something abnormal. PSA can also highlight other potential problems other than PCa.

Most of us realize that the incidence of prostate cancer increases with age but I believe you statement that ALL men who are 85 or older is an exaggeration.

The task force study provides interesting information but it seems to be throwing the baby out with the bathwater. Many men, myself included, were otherwise "healthy" when their PSA test signal led a problem. Many younger men are being diagnosed with more aggressive forms of PCa and have higher Gleason scores. Without the PSA test they could well be losing many years of life expectancy without early intervention.

Mrspjd has suggested concerned survivors register their concerns with the task force. I think it's a good idea.

K

mrspjd

Kongo said:

Obligatory
Hey, Vasco

What type of obligatory cancer prevention program would you suggest?

CALL TO ACTION & ADVOCACY
All,

If you’re concerned about the USPSTF’s draft report recommendations against PSA based screening for PCa and would like to learn how to make your comments heard, please read the “Call to Action” thread: http://csn.cancer.org/node/228042

P.S. Apparently, the "Call to Action" thread has been flagged by a CSN member. If the thread is removed, I encourage you to please visit the "Us Too" PCa website:

www.ustoo.org

Read the "Advocacy Alert" info on the left side of the Us Too home page to learn how you can make your comments heard by the USPSTF beginning Tuesday, October 11, 2011, and running through November 8, 2011. Thanks.

gottalottodo

VascodaGama said:

PSA is not problematic but it is not complete
The problem is not in the PSA but the interpretation and judgements that follow its findings. Physicians are not prepared to interpret accurately the tests’ meaning. Treatments are still primitive and guessing and do not address the cancer itself igniting thoughts like the “get rid of it”.
Reliable Institutions also fall in the trap and produce “Guidelines” which are antiquated to the occasion. Updates must be based on past experiences of many years and that turns the whole aspects of the prostate cancer ambiguous.

Prevention programs for cancer should be obligatory as must as are the vaccines we all take at young age.

Regards to all
VGama

sensitivity and specificity of PSA
As usual, VGama, you are right on, However, there are so many confounding variables in this chain!
I want to start with basic statistics. Make a 2x2 grid. To the left side of the grid, write cancer and under it no cancer. on the top write test positive over column 1 and test neg over column 2. so first box, starting in upper left is cancer and test positive [good; called true positive]. next, top right is cancer and test negative [bad, because cancer can grow undetected, called false negative]. Second line, lower left box no cancer and test positive [false positive - bad because workup and treatment not needed]. Last box, lower right is no cancer, test negative [true negative; good because nothing is indicated]. life would be good if after testing thousands, only true positives and true negatives exist. But that's not true of PSA. More alarming is that true positive doesn't necessarily mean that you go for it, as in the case above of breast cancer. You all have elegantly discussed the many other factors involved. each of us i believe have to interpret the findings from his own point of view. mine, for instance, is kind of sad [for me]. i had had years of PSAs done, starting soon after age 58 in 1997. they were normal but in retrospect slowly climbing to about 3.4 by 2002. I missed having a PSA done in July 2003 [usual time for annual physical]. I went directly to urologist in Feb 2004 because of frequency and nocturia, expecting to get prosgar for BPH. My PSA was 417, repeat 422. I had biopsies [8 of 10 positive and Gleason 7]. I wonder would PSA have been 8 months earlier??
I don't know if it would have indicated a tumor then treatable for cure. But i sure wish my internist and i hadn't forgotten to get a PSA when i was 'supposed to.' Now i'm a general surgeon and i remember Mike DeBakey, the famous heart surgeon from Texas. He was on the cover of Time and the quote was, "if they can operate, you're lucky." Of course, there were no other modalities of treatment then, long before angioplasty. Rephrase it as, "if they can kill it all" and we get to many of comments in this string and the dilemmas.

IMHO, the problem is simple. That concept is clearly too simplistic as the variation in prostate cancers preclude any sort of guidelines or decision tree based on hard data. so we want certainty when it just can't be there. We don't know enough. we do know people are working hard to find ways to distinguish among the good, the bad and the ugly cancers. Compared to esophageal cancer and pancreatic cancer we have it good. look up the pancreatic cancer survivor statistics. In the last 40 years, the % of survivors after surgery has risen from around 5% when i was a resident in the late 60s to perhaps 40% in series from Johns Hopkins and Mass General. But the NUMBER of survivors is about the same. they have multimodality screening devices that can now identify those cancers that can't be cures and so surgery is not offered. The improvement in diagnosis has decreased the number of patients who had no chance but it only be discovered at surgery.

What we, as advocates for prostate cancer patients, have to worry about has already been mentioned in this string and i repeat for the sake of emphasis. the news stories will not have the correct information. no one takes time to go back to the original sources. other media reporters on TV or individuals who act as authorities will quote [or rather further mis-quote] the original findings and they may be believed by people who then will do the wrong thing. then the disease will not be picked up too early and too often as it is now, leading to the bad outcomes of overtreatment. they will be like me. never had a chance for a cure. believe me, i was shocked when my urologist looked up from the lab report of 417 and told me that the level was usually associated with cancer beyond the prostate or stage 4 disease. The good news is that Lupron took care of me for 7 years. Casodex and DES bought me almost a year so i could get Provenge and now just started Zytiga.

I admire the depth of information that so many of you display in your comments. too bad new patients can't automatically be referred to this website after an 'abnormal' PSA. Here they could find people who had the time and wanted to explain the variables. Keep up the good work.

Swingshiftworker

Beau2 said:

FWIW2
Hey Swing,

I agree that the recommendation is to cut back on treatment (primarily surgery, brachy, radiation, etc.). Since CK and PBT are used primarily on low risk patients, I would have to agree with mrsjpd that CK and PBT would feel a hit. Or are you proposeing the CK and PBT docs will morph into high risk PCa specialists?

FWIW3
My thinking is that if ONLY CK, PBT or other less potentially damaging treatments are used to treat early stage PCa, the incidence of problems w/incontinence and ED will drop dramatically.

I believe that higher risk PCa could be treated by these methods now and the only reason they are not used for that purpose is a policy decision by the physicians/companies involved which I believe is motivated to enhance their "cure rates" in order to gain endorsement by medical providers and insurance companies for broader use. Remember, CK and PBT are still considered "experimental" treatments by some medical insurers and they still need to prove to that these methods are not "experimental."

I believe that some people are considering using CK w/higher risk patients on a trial basis but I see no reason why it couldn't work, especially if it's used like (IMRT is currently applied) in conjunction w/hormone therapy for higher risk patients. Some men like Larry chose surgery only because he was refused treatment by PBT (or other methods) because their policy was to treat only men w/Gleason 6 and a PSA less than 10. Their success rate might drop if they treated Gleason 7 or 8 men but it doesn't mean they wouldn't have any success w/such patients; just less than they would and have been achieving w/Gleaon 6 (which would be contrary to their current need to "prove" the efficacy of their treatment method).

However, if this were to happen, I believe the use of CK & PBT (and HIFU, if it ever gets past it's "experimental" reputation) would rise at the expense of surgery, which (to my mind) would be a very good thing and would certainly result in a much lower incidence of incontinence, ED and other problems known to be caused ONLY by surgery without lowering the overall "cure" rate.

Kongo

gottalottodo said:

sensitivity and specificity of PSA
As usual, VGama, you are right on, However, there are so many confounding variables in this chain!
I want to start with basic statistics. Make a 2x2 grid. To the left side of the grid, write cancer and under it no cancer. on the top write test positive over column 1 and test neg over column 2. so first box, starting in upper left is cancer and test positive [good; called true positive]. next, top right is cancer and test negative [bad, because cancer can grow undetected, called false negative]. Second line, lower left box no cancer and test positive [false positive - bad because workup and treatment not needed]. Last box, lower right is no cancer, test negative [true negative; good because nothing is indicated]. life would be good if after testing thousands, only true positives and true negatives exist. But that's not true of PSA. More alarming is that true positive doesn't necessarily mean that you go for it, as in the case above of breast cancer. You all have elegantly discussed the many other factors involved. each of us i believe have to interpret the findings from his own point of view. mine, for instance, is kind of sad [for me]. i had had years of PSAs done, starting soon after age 58 in 1997. they were normal but in retrospect slowly climbing to about 3.4 by 2002. I missed having a PSA done in July 2003 [usual time for annual physical]. I went directly to urologist in Feb 2004 because of frequency and nocturia, expecting to get prosgar for BPH. My PSA was 417, repeat 422. I had biopsies [8 of 10 positive and Gleason 7]. I wonder would PSA have been 8 months earlier??
I don't know if it would have indicated a tumor then treatable for cure. But i sure wish my internist and i hadn't forgotten to get a PSA when i was 'supposed to.' Now i'm a general surgeon and i remember Mike DeBakey, the famous heart surgeon from Texas. He was on the cover of Time and the quote was, "if they can operate, you're lucky." Of course, there were no other modalities of treatment then, long before angioplasty. Rephrase it as, "if they can kill it all" and we get to many of comments in this string and the dilemmas.

IMHO, the problem is simple. That concept is clearly too simplistic as the variation in prostate cancers preclude any sort of guidelines or decision tree based on hard data. so we want certainty when it just can't be there. We don't know enough. we do know people are working hard to find ways to distinguish among the good, the bad and the ugly cancers. Compared to esophageal cancer and pancreatic cancer we have it good. look up the pancreatic cancer survivor statistics. In the last 40 years, the % of survivors after surgery has risen from around 5% when i was a resident in the late 60s to perhaps 40% in series from Johns Hopkins and Mass General. But the NUMBER of survivors is about the same. they have multimodality screening devices that can now identify those cancers that can't be cures and so surgery is not offered. The improvement in diagnosis has decreased the number of patients who had no chance but it only be discovered at surgery.

What we, as advocates for prostate cancer patients, have to worry about has already been mentioned in this string and i repeat for the sake of emphasis. the news stories will not have the correct information. no one takes time to go back to the original sources. other media reporters on TV or individuals who act as authorities will quote [or rather further mis-quote] the original findings and they may be believed by people who then will do the wrong thing. then the disease will not be picked up too early and too often as it is now, leading to the bad outcomes of overtreatment. they will be like me. never had a chance for a cure. believe me, i was shocked when my urologist looked up from the lab report of 417 and told me that the level was usually associated with cancer beyond the prostate or stage 4 disease. The good news is that Lupron took care of me for 7 years. Casodex and DES bought me almost a year so i could get Provenge and now just started Zytiga.

I admire the depth of information that so many of you display in your comments. too bad new patients can't automatically be referred to this website after an 'abnormal' PSA. Here they could find people who had the time and wanted to explain the variables. Keep up the good work.

Great Perspective
Thanks for the superb post, gotta. I'm sure we all appreciate your informed perspective. Wishing you continued success in your battle.

K

hunter49

My PSA in August was 4.1 up
My PSA in August was 4.1 up from 2.54 in 4/09. I could have ewaited instead I went for a biopsy right away and one out of 15 was posative with 95% and a gleason of 3+4. Had I waited 6 months who knows. All scans were clear. One of my best friends is an oncologist who works on reasearch for PC and pancreatic.. They are doing some real cutting edge stuff aat Hopkins. His simple reply is the reason we are having success with vaccines with prostate as a opposed to pancreatic is early detection. A psa is not a diagnosis but a warning light. As a former naval fighter pilot you relied on indicator lights to avoid disaster. Like a pilot, doctors need to be trained as to what the indicator light is warning, process the information and react. However, if the light indicated fire you move quickly. If it was a back up gauge or electronics you watch it. A high PSA or one doubling in a year indicates fire so react. After you assertain it is cancer then fully research your options and move. Cancer does not wait for you to come and get it.

hunter49

My PSA in August was 4.1 up
My PSA in August was 4.1 up from 2.54 in 4/09. I could have ewaited instead I went for a biopsy right away and one out of 15 was posative with 95% and a gleason of 3+4. Had I waited 6 months who knows. All scans were clear. One of my best friends is an oncologist who works on reasearch for PC and pancreatic.. They are doing some real cutting edge stuff aat Hopkins. His simple reply is the reason we are having success with vaccines with prostate as a opposed to pancreatic is early detection. A psa is not a diagnosis but a warning light. As a former naval fighter pilot you relied on indicator lights to avoid disaster. Like a pilot, doctors need to be trained as to what the indicator light is warning, process the information and react. However, if the light indicated fire you move quickly. If it was a back up gauge or electronics you watch it. A high PSA or one doubling in a year indicates fire so react. After you assertain it is cancer then fully research your options and move. Cancer does not wait for you to come and get it.

hunter49

My PSA in August was 4.1 up
My PSA in August was 4.1 up from 2.54 in 4/09. I could have ewaited instead I went for a biopsy right away and one out of 15 was posative with 95% and a gleason of 3+4. Had I waited 6 months who knows. All scans were clear. One of my best friends is an oncologist who works on reasearch for PC and pancreatic.. They are doing some real cutting edge stuff aat Hopkins. His simple reply is the reason we are having success with vaccines with prostate as a opposed to pancreatic is early detection. A psa is not a diagnosis but a warning light. As a former naval fighter pilot you relied on indicator lights to avoid disaster. Like a pilot, doctors need to be trained as to what the indicator light is warning, process the information and react. However, if the light indicated fire you move quickly. If it was a back up gauge or electronics you watch it. A high PSA or one doubling in a year indicates fire so react. After you assertain it is cancer then fully research your options and move. Cancer does not wait for you to come and get it.

jerrylh

Kongo said:

Question
Jerry,

Are you a prostate cancer survivor? If so, how were you diagnosed? Most men, in my opinion, are grateful for the information the PSA test provided. They may well be unhappy with the results of their treatment but I am sure most men want to know if their PSA test even remotely suggests something abnormal. PSA can also highlight other potential problems other than PCa.

Most of us realize that the incidence of prostate cancer increases with age but I believe you statement that ALL men who are 85 or older is an exaggeration.

The task force study provides interesting information but it seems to be throwing the baby out with the bathwater. Many men, myself included, were otherwise "healthy" when their PSA test signal led a problem. Many younger men are being diagnosed with more aggressive forms of PCa and have higher Gleason scores. Without the PSA test they could well be losing many years of life expectancy without early intervention.

Mrspjd has suggested concerned survivors register their concerns with the task force. I think it's a good idea.

K

Kongo
Hi Kongo

I am 69 and I have always told my doctor NOT to order a PSA.

Remember. These guidelines are for ASYMPTOMATIC males. If you wait until, let's say you have blood in your urine, and then get a work up for prostate cancer, your odds of survival are the same as if you had had a PSA and an earlier diagnosis. Please try to understand, NO ONE IS SAYING DON'T TREAT PROSTATE CANCER. What is being said is to wait until you have symptoms. Your survival is not decreased by waiting for symptoms. BTW, it is the same for lung cancer.

LOOK, I know it sounds intuitive that PSA screening would save lives. I know that it is counter-intuitive that waiting for symptoms won't affect survival. However, there has never been a double blind study that showed an improvement in all cause mortality with PSA screening in ASYMPTOMATIC MALES. There have now been 4 studies that failed to show improvement in all-cause mortality. The last two were Swedish studies. Sweden has a socialized medical system, so they were able to randomize patients to screening PSA or no screening PSA. In the end, there was no different in all cause mortality.

Thanks,

Jerry

jerrylh

hunter49 said:

My PSA in August was 4.1 up
My PSA in August was 4.1 up from 2.54 in 4/09. I could have ewaited instead I went for a biopsy right away and one out of 15 was posative with 95% and a gleason of 3+4. Had I waited 6 months who knows. All scans were clear. One of my best friends is an oncologist who works on reasearch for PC and pancreatic.. They are doing some real cutting edge stuff aat Hopkins. His simple reply is the reason we are having success with vaccines with prostate as a opposed to pancreatic is early detection. A psa is not a diagnosis but a warning light. As a former naval fighter pilot you relied on indicator lights to avoid disaster. Like a pilot, doctors need to be trained as to what the indicator light is warning, process the information and react. However, if the light indicated fire you move quickly. If it was a back up gauge or electronics you watch it. A high PSA or one doubling in a year indicates fire so react. After you assertain it is cancer then fully research your options and move. Cancer does not wait for you to come and get it.

For Kongo
Kongo
new
Hi Kongo

I am 69 and I have always told my doctor NOT to order a PSA.

Remember. These guidelines are for ASYMPTOMATIC males. If you wait until, let's say you have blood in your urine, and then get a work up for prostate cancer, your odds of survival are the same as if you had had a PSA and an earlier diagnosis. Please try to understand, NO ONE IS SAYING DON'T TREAT PROSTATE CANCER. What is being said is to wait until you have symptoms. Your survival is not decreased by waiting for symptoms. BTW, it is the same for lung cancer.

LOOK, I know it sounds intuitive that PSA screening would save lives. I know that it is counter-intuitive that waiting for symptoms won't affect survival. However, there has never been a double blind study that showed an improvement in all cause mortality with PSA screening in ASYMPTOMATIC MALES. There have now been 4 studies that failed to show improvement in all-cause mortality. The last two were Swedish studies. Sweden has a socialized medical system, so they were able to randomize patients to screening PSA or no screening PSA. In the end, there was no different in all cause mortality.

Thanks,

Jerry

hopeful and optimistic

mrspjd said:

CALL TO ACTION & ADVOCACY
All,

If you’re concerned about the USPSTF’s draft report recommendations against PSA based screening for PCa and would like to learn how to make your comments heard, please read the “Call to Action” thread: http://csn.cancer.org/node/228042

P.S. Apparently, the "Call to Action" thread has been flagged by a CSN member. If the thread is removed, I encourage you to please visit the "Us Too" PCa website:

www.ustoo.org

Read the "Advocacy Alert" info on the left side of the Us Too home page to learn how you can make your comments heard by the USPSTF beginning Tuesday, October 11, 2011, and running through November 8, 2011. Thanks.

I forward the call to action thread to my contacts
I hope that others will do the same

To make it easy, here is a sample cover letter

Here is information about the new guidelines that are being proposed about PSA testing. You will find this informative.

The below reference is taken from a site that I frequent provided by the American Cancer . www.csn.cancer.org

This site is very informative to those of you who are interested in gaining knowledge about prostate cancer.

Please feel free to comment to this action committee starting on Tuesday.

Here is the thread http://csn.cancer.org/node/228042

Kongo

jerrylh said:

For Kongo
Kongo
new
Hi Kongo

I am 69 and I have always told my doctor NOT to order a PSA.

Remember. These guidelines are for ASYMPTOMATIC males. If you wait until, let's say you have blood in your urine, and then get a work up for prostate cancer, your odds of survival are the same as if you had had a PSA and an earlier diagnosis. Please try to understand, NO ONE IS SAYING DON'T TREAT PROSTATE CANCER. What is being said is to wait until you have symptoms. Your survival is not decreased by waiting for symptoms. BTW, it is the same for lung cancer.

LOOK, I know it sounds intuitive that PSA screening would save lives. I know that it is counter-intuitive that waiting for symptoms won't affect survival. However, there has never been a double blind study that showed an improvement in all cause mortality with PSA screening in ASYMPTOMATIC MALES. There have now been 4 studies that failed to show improvement in all-cause mortality. The last two were Swedish studies. Sweden has a socialized medical system, so they were able to randomize patients to screening PSA or no screening PSA. In the end, there was no different in all cause mortality.

Thanks,

Jerry

Thanks
Jerry,

I appreciate your perspective. I just don't happen to agree with it. I do pretty much agree with Dr. Albin, the researcher who discovered the PSA test we use today that the PSA test has been greatly abused by the medical community and has likely led to a tremendous amount of over treatment in the United States. I believe Dr. Albin’s position is that it’s the way this information is handled, not the test itself, which is the problem here. I share the opinion that the problem is not with the test itself...it's how the results of the test have been used (either deliberately or with all the best intentions) to scare men ignorant of the nuances of prostate cancer into getting treatment that often leads to a much worse quality of life than cancer may have produced.

An individual PSA score is just a number. A single data point. But when several PSA scores are recorded over several years a very different perspective of testing PSA emerges. With several tests we can calculate a PSA doubling time that can give an indication that prostate cancer may be growing. It can be used to calculate PSA velocity and, when used with an accurate reading of the prostate volume, PSA can be used to determine the PSA density within the prostate. There are several studies that show the value of using PSADT, PSA velocity, and PSA density to determine the relative threat of prostate cancer. The task force chose not to address these issues and I wonder if the reason was because it didn't jive with the committee's draft conclusion.

While most prostate cancers are slow growing strains, there are a few of the twenty odd PCa variants that are very aggressive. Since PSA can't suggest whether or not you are harboring one of these more virulent types I would imagine that most men would want the opportunity to treat it as early as possible while there is a reasonable chance it is contained within the prostate gland. We all know that the higher Gleason scores have a much higher risk of seeing the cancer move beyond the prostate and settle in some other organ. We also know that once prostate cancer moves beyond the prostate it tends to grow faster than before.

From your post it seems that you have not had to personally deal with the decisions about what to do with a prostate diagnosis. I certainly hope that you never do. But those of us who have had to deal with it are, for the most part I suspect, grateful to have at least been given the opportunity to make choices about what to do. Whether we make the most appropriate choices for our diagnosis is another matter entirely and I think you would agree with me that men should proceed with prostate cancer treatment options very, very carefully and be fully informed about what they're signing up for. This is why I suggested in an earlier post that an ombudsman belongs in the process without ties to the insurance community or diagnosing physicians that could help steer the newly diagnosed patient through their options.

I certainly respect your decision to avoid ordering a PSA test when you have routine blood work drawn but frankly, I don't understand why you would forego the potentially valuable information a well documented history of PSA testing could provide you and your medical team when making a decision should you ever have prostate cancer. It is always your choice to avoid a biopsy or further investigative testing and you seem well versed in the issues surrounding testing. So why not have the test done?

If I had been half as smart about PSA when it popped above 4.0 20 months ago as I am today, I would have handled it entirely differently. Whether or not I would have ended up making the same treatment choices I did is something I will never know. As it is I chose an approach (CyberKnife) to minimize quality of life issues and treat an early-detected prostate cancer with a favorable pathology after much research and consultation with many specialists. Having the PSA history I did was a major factor in helping me frame the actual threat of prostate cancer given the information that was available to me at the time.

Many men with very advanced prostate cancer have no symptoms, as you know. If we waited until symptoms to do a PSA test, I do believe that many more men would die before their time.

I understand that a major crux of your position is that in large population studies there is no difference in all cause mortality between those who were treated early and those that waited until they were symptomatic. That is a strong argument if we were only making decisions based on the large population studies cited by the task force or had a health care system that was focused solely on the bottom line. But despite what the studies chosen by the task force show, I recall reading other studies that indicated that men who followed watchful waiting after low threat diagnosis had a higher prostate specific mortality than those who chose RP. If your argument about it not making any difference were correct, then I would think that these numbers would be the same. (See http://www.nejm.org/doi/full/10.1056/NEJMoa043739 from the New England Journal of Medicine) Another study from Sweden showed similar statistics (http://jnci.oxfordjournals.org/content/100/16/1144.short). I am not aware of any studies that compare long term all source mortality with the newer forms of radiation such as CyberKnife or IMRT. I don’t think it’s been long enough.

My impression when I reviewed the task force data, and please correct me if I’ve missed something, that they chose studies that supported their draft conclusion and chose to ignore studies that suggested a decreased all source mortality rate through early stage action triggered, presumably, by a PSA test.

Certainly this is an important debate although I do understand why men who feel that their lives have been saved by a simple PSA test would be emotional about it. I do appreciate your perspective, but I remain convinced that there’s nothing wrong with the PSA test…it’s how we handle the information. And I do hope that someday soon we find a better way of diagnosing prostate cancer and the relative threat to our health than the way we do it today.

As mrspjd suggested, those who feel strongly one way or the other should take the opportunity to respond directly to the task force in th appropriate forum.

Best,

K

jerrylh

Kongo said:

Thanks
Jerry,

I appreciate your perspective. I just don't happen to agree with it. I do pretty much agree with Dr. Albin, the researcher who discovered the PSA test we use today that the PSA test has been greatly abused by the medical community and has likely led to a tremendous amount of over treatment in the United States. I believe Dr. Albin’s position is that it’s the way this information is handled, not the test itself, which is the problem here. I share the opinion that the problem is not with the test itself...it's how the results of the test have been used (either deliberately or with all the best intentions) to scare men ignorant of the nuances of prostate cancer into getting treatment that often leads to a much worse quality of life than cancer may have produced.

An individual PSA score is just a number. A single data point. But when several PSA scores are recorded over several years a very different perspective of testing PSA emerges. With several tests we can calculate a PSA doubling time that can give an indication that prostate cancer may be growing. It can be used to calculate PSA velocity and, when used with an accurate reading of the prostate volume, PSA can be used to determine the PSA density within the prostate. There are several studies that show the value of using PSADT, PSA velocity, and PSA density to determine the relative threat of prostate cancer. The task force chose not to address these issues and I wonder if the reason was because it didn't jive with the committee's draft conclusion.

While most prostate cancers are slow growing strains, there are a few of the twenty odd PCa variants that are very aggressive. Since PSA can't suggest whether or not you are harboring one of these more virulent types I would imagine that most men would want the opportunity to treat it as early as possible while there is a reasonable chance it is contained within the prostate gland. We all know that the higher Gleason scores have a much higher risk of seeing the cancer move beyond the prostate and settle in some other organ. We also know that once prostate cancer moves beyond the prostate it tends to grow faster than before.

From your post it seems that you have not had to personally deal with the decisions about what to do with a prostate diagnosis. I certainly hope that you never do. But those of us who have had to deal with it are, for the most part I suspect, grateful to have at least been given the opportunity to make choices about what to do. Whether we make the most appropriate choices for our diagnosis is another matter entirely and I think you would agree with me that men should proceed with prostate cancer treatment options very, very carefully and be fully informed about what they're signing up for. This is why I suggested in an earlier post that an ombudsman belongs in the process without ties to the insurance community or diagnosing physicians that could help steer the newly diagnosed patient through their options.

I certainly respect your decision to avoid ordering a PSA test when you have routine blood work drawn but frankly, I don't understand why you would forego the potentially valuable information a well documented history of PSA testing could provide you and your medical team when making a decision should you ever have prostate cancer. It is always your choice to avoid a biopsy or further investigative testing and you seem well versed in the issues surrounding testing. So why not have the test done?

If I had been half as smart about PSA when it popped above 4.0 20 months ago as I am today, I would have handled it entirely differently. Whether or not I would have ended up making the same treatment choices I did is something I will never know. As it is I chose an approach (CyberKnife) to minimize quality of life issues and treat an early-detected prostate cancer with a favorable pathology after much research and consultation with many specialists. Having the PSA history I did was a major factor in helping me frame the actual threat of prostate cancer given the information that was available to me at the time.

Many men with very advanced prostate cancer have no symptoms, as you know. If we waited until symptoms to do a PSA test, I do believe that many more men would die before their time.

I understand that a major crux of your position is that in large population studies there is no difference in all cause mortality between those who were treated early and those that waited until they were symptomatic. That is a strong argument if we were only making decisions based on the large population studies cited by the task force or had a health care system that was focused solely on the bottom line. But despite what the studies chosen by the task force show, I recall reading other studies that indicated that men who followed watchful waiting after low threat diagnosis had a higher prostate specific mortality than those who chose RP. If your argument about it not making any difference were correct, then I would think that these numbers would be the same. (See http://www.nejm.org/doi/full/10.1056/NEJMoa043739 from the New England Journal of Medicine) Another study from Sweden showed similar statistics (http://jnci.oxfordjournals.org/content/100/16/1144.short). I am not aware of any studies that compare long term all source mortality with the newer forms of radiation such as CyberKnife or IMRT. I don’t think it’s been long enough.

My impression when I reviewed the task force data, and please correct me if I’ve missed something, that they chose studies that supported their draft conclusion and chose to ignore studies that suggested a decreased all source mortality rate through early stage action triggered, presumably, by a PSA test.

Certainly this is an important debate although I do understand why men who feel that their lives have been saved by a simple PSA test would be emotional about it. I do appreciate your perspective, but I remain convinced that there’s nothing wrong with the PSA test…it’s how we handle the information. And I do hope that someday soon we find a better way of diagnosing prostate cancer and the relative threat to our health than the way we do it today.

As mrspjd suggested, those who feel strongly one way or the other should take the opportunity to respond directly to the task force in th appropriate forum.

Best,

K

for Kongo
Hi Kongo

I appreciate you perceptive comments. A couple of clarifications. There are four major studies. The USPSTF didn't ignore anything. Two of the four studies did show a decrease in deaths due to prostate cancer. For example the widely respected European study showed a decrease in the death rate due to prostate cancer of 28%. The reaction to that is to say, "hey screening works." That is until you look closely at the numbers.
The death rate for prostate cancer is 2.5-3.0% That means that for every 1000 patients with prostate cancer 25-30 will die of their disease. A 28% decrease means that approximately 7 patients of 1000 with prostate cancer will be saved. Now comes the rub. The death rate for prostatectomy is 0.5 to 1.0% or about 7.5 patient will die from the surgery. What you have to look at "all cause mortality" not death due to prostate cancer.

About a year ago, Dr. Ablin wrote an extensive editorial in the New York Times decrying PSA screening. He called it the great prostate mistake. http://www.nytimes.com/2010/03/10/opinion/10Ablin.html. It makes for interesting reading. Let me know what you think

Regards,

Jerry

VascodaGama

jerrylh said:

for Kongo
Hi Kongo

I appreciate you perceptive comments. A couple of clarifications. There are four major studies. The USPSTF didn't ignore anything. Two of the four studies did show a decrease in deaths due to prostate cancer. For example the widely respected European study showed a decrease in the death rate due to prostate cancer of 28%. The reaction to that is to say, "hey screening works." That is until you look closely at the numbers.
The death rate for prostate cancer is 2.5-3.0% That means that for every 1000 patients with prostate cancer 25-30 will die of their disease. A 28% decrease means that approximately 7 patients of 1000 with prostate cancer will be saved. Now comes the rub. The death rate for prostatectomy is 0.5 to 1.0% or about 7.5 patient will die from the surgery. What you have to look at "all cause mortality" not death due to prostate cancer.

About a year ago, Dr. Ablin wrote an extensive editorial in the New York Times decrying PSA screening. He called it the great prostate mistake. http://www.nytimes.com/2010/03/10/opinion/10Ablin.html. It makes for interesting reading. Let me know what you think

Regards,

Jerry

GOTTALOTTODO;I want to see more Physicians with similar Opinions
Gottalottodo

I am very happy for seeing your post and would like to thank you for sharing your story.
Your experiences as a survivor and as a professional physician of many years in practice are impressive. I have nothing to add with regards to the theme of this thread. As you commented PSA is not a baton to judge “trues” and “falses” in complete symphony with other elements. It falls short to the expectations that many of us put on it.

I am not a physician but an avid student since being diagnosed in 2000. I have participated in cancer conferences as a patient and have exchanged opinions with doctors in regards to PCa. My researches have given me the understanding I need for being positive along my survival.

In your PCa case, the trend of the results you got during the five years of tests should have raised a flag to your real status, back in 2002. I doubt that the aggressiveness of our cancers would increase in a span of two years without a cause. Cancer in my opinion maintains its “basics” and replicates as far as our system “allows it”. The behaviourism of indolent slow-grow to active fast-grow is due to alterations influencing those “basics”. Moments of stress, anxiety, body biorhythm or event treatment interventions can cause variations in our “defences” and lead to sudden “explosions” of activity in cells. You may have had something that can be related to the moment causing that sudden explosion represented in the fast increase of antigens from 4 to 400.

Each ones cancer behaves differently in regards to influences one is subjected to, and that leads to similarities but not to equalities. I relate my case to STRESS.
Nevertheless, earlier and timely prevention programs should set a series of instructions to avoid those moments of “forgottenness” or “lost chances in cure”, and they should be informative and clear about what each precautious item represents. “Certainty” would be closer and would serve you guys (surgeons) with a better “tool” in the decision of a timely intervention.

I sympathise with your expression that our cancer is qualified in the group of the “good” ones, in spite of being not that good for you. My own qualification of treatments is in a sequential scale as; the Manageable, the Treatable and the Controllable. Those should be included in the prevention programs.

I would appreciate if you could give us the chronology of your PSAs while on treatment (since 2004).

Thanks for the post and good luck in your continuous journey.

VGama

ProfWagstaff

I'm the poster boy for the opposition to the recommendation
I was one of those guys who NEVER went to a doctor. My motto was, "If there's not a bone poking through skin, I don't need a doctor." My younger brother was diagnosed with PCa and his urologist told him to get me screened. After several months of nagging, I went for a screening just to shut him up and prove that I was fine. PSA was 20.4 and I was at stage T2c with no symptoms. If I had followed the recommendation and not gone for a check, it may not have been detected until too late. I might have been terminal by now instead of having been treated and have an undetectable PSA again. The recommendation is short-sighted and will likely sacrifice many good men.

Swingshiftworker

jerrylh said:

for Kongo
Hi Kongo

I appreciate you perceptive comments. A couple of clarifications. There are four major studies. The USPSTF didn't ignore anything. Two of the four studies did show a decrease in deaths due to prostate cancer. For example the widely respected European study showed a decrease in the death rate due to prostate cancer of 28%. The reaction to that is to say, "hey screening works." That is until you look closely at the numbers.
The death rate for prostate cancer is 2.5-3.0% That means that for every 1000 patients with prostate cancer 25-30 will die of their disease. A 28% decrease means that approximately 7 patients of 1000 with prostate cancer will be saved. Now comes the rub. The death rate for prostatectomy is 0.5 to 1.0% or about 7.5 patient will die from the surgery. What you have to look at "all cause mortality" not death due to prostate cancer.

About a year ago, Dr. Ablin wrote an extensive editorial in the New York Times decrying PSA screening. He called it the great prostate mistake. http://www.nytimes.com/2010/03/10/opinion/10Ablin.html. It makes for interesting reading. Let me know what you think

Regards,

Jerry

Death as a result of surgery?!!
Thanks for bringing up that point!

I don't think it's ever been discussed here before.

My focus (as a prospective patient who chose CK instead) has always been on the primary side effects following the survival of surgery -- mainly ED and incontinence (temporary and permanent) -- but also on the lesser but extreme possibility of worst things, such as hemorrhaging, infections and/or malpractice related injuries to the rectum and bladder.

I never really focused on the possibility of DEATH following surgery but it's an obvious risk that exists and is just another reason why (as remote as the risk may be) men should, if at all possible, avoid letting anyone cut them open to take the prostate out unless ABSOLUTELY necessary.

mrspjd

gottalottodo said:

sensitivity and specificity of PSA
As usual, VGama, you are right on, However, there are so many confounding variables in this chain!
I want to start with basic statistics. Make a 2x2 grid. To the left side of the grid, write cancer and under it no cancer. on the top write test positive over column 1 and test neg over column 2. so first box, starting in upper left is cancer and test positive [good; called true positive]. next, top right is cancer and test negative [bad, because cancer can grow undetected, called false negative]. Second line, lower left box no cancer and test positive [false positive - bad because workup and treatment not needed]. Last box, lower right is no cancer, test negative [true negative; good because nothing is indicated]. life would be good if after testing thousands, only true positives and true negatives exist. But that's not true of PSA. More alarming is that true positive doesn't necessarily mean that you go for it, as in the case above of breast cancer. You all have elegantly discussed the many other factors involved. each of us i believe have to interpret the findings from his own point of view. mine, for instance, is kind of sad [for me]. i had had years of PSAs done, starting soon after age 58 in 1997. they were normal but in retrospect slowly climbing to about 3.4 by 2002. I missed having a PSA done in July 2003 [usual time for annual physical]. I went directly to urologist in Feb 2004 because of frequency and nocturia, expecting to get prosgar for BPH. My PSA was 417, repeat 422. I had biopsies [8 of 10 positive and Gleason 7]. I wonder would PSA have been 8 months earlier??
I don't know if it would have indicated a tumor then treatable for cure. But i sure wish my internist and i hadn't forgotten to get a PSA when i was 'supposed to.' Now i'm a general surgeon and i remember Mike DeBakey, the famous heart surgeon from Texas. He was on the cover of Time and the quote was, "if they can operate, you're lucky." Of course, there were no other modalities of treatment then, long before angioplasty. Rephrase it as, "if they can kill it all" and we get to many of comments in this string and the dilemmas.

IMHO, the problem is simple. That concept is clearly too simplistic as the variation in prostate cancers preclude any sort of guidelines or decision tree based on hard data. so we want certainty when it just can't be there. We don't know enough. we do know people are working hard to find ways to distinguish among the good, the bad and the ugly cancers. Compared to esophageal cancer and pancreatic cancer we have it good. look up the pancreatic cancer survivor statistics. In the last 40 years, the % of survivors after surgery has risen from around 5% when i was a resident in the late 60s to perhaps 40% in series from Johns Hopkins and Mass General. But the NUMBER of survivors is about the same. they have multimodality screening devices that can now identify those cancers that can't be cures and so surgery is not offered. The improvement in diagnosis has decreased the number of patients who had no chance but it only be discovered at surgery.

What we, as advocates for prostate cancer patients, have to worry about has already been mentioned in this string and i repeat for the sake of emphasis. the news stories will not have the correct information. no one takes time to go back to the original sources. other media reporters on TV or individuals who act as authorities will quote [or rather further mis-quote] the original findings and they may be believed by people who then will do the wrong thing. then the disease will not be picked up too early and too often as it is now, leading to the bad outcomes of overtreatment. they will be like me. never had a chance for a cure. believe me, i was shocked when my urologist looked up from the lab report of 417 and told me that the level was usually associated with cancer beyond the prostate or stage 4 disease. The good news is that Lupron took care of me for 7 years. Casodex and DES bought me almost a year so i could get Provenge and now just started Zytiga.

I admire the depth of information that so many of you display in your comments. too bad new patients can't automatically be referred to this website after an 'abnormal' PSA. Here they could find people who had the time and wanted to explain the variables. Keep up the good work.

USPSTF currently accepting public comment
The USPSTF has posted their draft report on their website here:
http://www.uspreventiveservicestaskforce.org/uspstf12/prostate/draftrecprostate.htm

The Task Force will be accepting comments on this draft recommendation statement beginning on Tuesday, October 11, 2011, and running through November 8, 2011.

Everyone is encouraged to post their comments (pro or con) beginning Tuesday, October 11th at this website:
http://www.uspreventiveservicestaskforce.org/tfcomment.htm

mrspjd

hopeful and optimistic said:

I forward the call to action thread to my contacts
I hope that others will do the same

To make it easy, here is a sample cover letter

Here is information about the new guidelines that are being proposed about PSA testing. You will find this informative.

The below reference is taken from a site that I frequent provided by the American Cancer . www.csn.cancer.org

This site is very informative to those of you who are interested in gaining knowledge about prostate cancer.

Please feel free to comment to this action committee starting on Tuesday.

Here is the thread http://csn.cancer.org/node/228042

Thank you, CSN
The "Call to Action" thread: http://csn.cancer.org/node/228042 has been UNFLAGGED by CSN and remains posted! I assume this means that the thread will stay up even if flagged again. Thanks to CSN admin for keeping the thread on the board.

Appreciate your support and help in getting the word out on this important issue.

Again, MANY THANKS to CSN!

VascodaGama

ProfWagstaff said:

I'm the poster boy for the opposition to the recommendation
I was one of those guys who NEVER went to a doctor. My motto was, "If there's not a bone poking through skin, I don't need a doctor." My younger brother was diagnosed with PCa and his urologist told him to get me screened. After several months of nagging, I went for a screening just to shut him up and prove that I was fine. PSA was 20.4 and I was at stage T2c with no symptoms. If I had followed the recommendation and not gone for a check, it may not have been detected until too late. I might have been terminal by now instead of having been treated and have an undetectable PSA again. The recommendation is short-sighted and will likely sacrifice many good men.

Prostate cancer screening, revisited
A powerful comment by Dr. Charles Myers in regards to the latest US Preventive Services Task Force’s (USPSTF) draft recommendation on prostate cancer screening (PSA). He recalls times of Vietnam when returning soldiers were treated badly.

Bulls**t are his pragmatic words to the panellists.

I am glad to know that he pairs with us on the matter, as a patient and doctor.

Here is the video;
http://askdrmyers.wordpress.com/?mkt_tok=3RkMMJWWfF9wsRonuqXJZKXonjHpfsXx6OosT/rn28M3109ad+rmPBy+2IYGWoEnZ9mMBAQZC81x0gNLDuGBeYZP6OBQ

VG