PSA Test Not Needed?? CNN posted today

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

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

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.

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

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.

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

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.

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.