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A serious PSA test thread (long beginning)
Old 10-14-2011, 08:25 AM   #1
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A serious PSA test thread (long beginning)

We are having fun talking about orgasms and prostate cancer over on a vitamin E thread but the new recommendation on the PSA test raise serious question that all of the men on this board will need to address. On a biking forum I frequent there is a good discussion going on but I would like to see what the smart folks over here are thinking (not that the bike crowd is dumb).

So, if you can stand reading it here is a longish intro from my point of view quoting a couple of posts from the other forum. First this is the post that started the thread. It contains a link to the recommendations:
Current "draft" recommendation by the US Preventive Services Task Force for PSA testing is to do away with it for men under 75.

"The common perception that PSA-based early detection of prostate cancer saves lives is simply not supported by the scientific evidence," task force co-vice chair Michael L. LeFevre, MD, MSPH, professor of family and community medicine at the University of Missouri, tells WebMD.

Read the draft recommendations here.

Your thoughts?
After a lot of back and forth I weighed in with my summary of the recommendations (no naked links):
After all this back and forth about what the "study" said I read the linked article (It isn't a study, it is a recommendation based on a lot of studies). What it says (or at least what I think it says) can be distilled to this. Most men who get a positive PSA test will go on to get a biopsy. But about 80% of those results are false positives so those guys get the negatives of a biopsy for naught. Of those whose biopsies show a cancer almost all of them will have treatment even though though most of the cancers would progress slowly and never have resulted in clinical symptoms before death from other causes. The aggressive or otherwise dangerous cancers will be detected later by clinical symptoms and would then be treated anyway. So the net result of screen is a lot of angst and earlier treatment of some cancers. It is those few guys who will get the earlier treatment of dangerous tumors that we are concerned with and why some of us have supported getting the screen. BUT, the statistics show that the benefits are minimal or none. The studies found NO advantages from screening for men over 70. And the studies showed marginal if any benefits for men 59-70. From the recommendation: "The evidence is convincing that for men aged 70 years and older, screening has no mortality benefit. For men aged 50 to 69 years, the evidence is convincing that the reduction in prostate cancer mortality 10 years after screening is small to none." If all of this is accurate then most (maybe not all) of the guys who got early treatment due to the test/biopsy would have gotten treatment later due to clinical syptoms and would end up with a similar result. The recommendation is to rely on clinical symptoms, not PSA screening to counsel a biopsy and subsequent treatment if a cancer is found. They are saying YOU are better off waiting for symptoms before getting a biopsy. This is not a cost tradeoff it is a straight benefit to you recommendation. Here is another quote:
"The common perception that PSA-based early detection of prostate cancer prolongs lives is not supported by the scientific evidence. The findings of the two largest trials highlight the uncertainty that remains about the precise effect that screening may have, and demonstrate that if any benefit does exist, it is very small after 10 years. The European trial found a statistically insignificant 0.06% absolute reduction in prostate cancer deaths for men aged 50 to 74 years, while the U.S. trial found a statistically insignificant 0.03% absolute increase in prostate cancer deaths (6, 7). A meta-analysis of all published trials found no statistically significant reduction in prostate cancer deaths (10). At the same time, overdiagnosis and overtreatment of prostatic tumors that will not progress to cause illness or death are frequent consequences of PSA-based screening. Although about 90% of men are currently treated for PSA-detected prostate cancer in the United States—usually with surgery or radiotherapy—the vast majority of men who are treated do not have prostate cancer death prevented or lives extended from that treatment, but are subjected to significant harms."
From a money perspective it seems like the test simply pumps money into the medical system with no evidence that the money makes a difference. Since the advent of testing a million men have had surgeries/radiation who would not have had them otherwise: "From 1986 through 2005, PSA-based screening likely resulted in approximately 1 million additional U.S. men being treated with surgery, radiation therapy, or both compared with before the test was introduced."

I plan to talk to my primary care physician about this at my next physical. My inclination would be to skip the PSA screen and rely on clinical symptoms. But I would be open to a rational discussion about why I might be wrong.
Tons of debate followed by a good post from a doctor:
What you need to know about studies like this one on the value of PSA testing is that they draw their statistical conclusions from populations rather than individuals. This allows the researchers to conclude that routine PSA screening for cancer in "younger" individuals doesn't show much "benefit" (again in terms of population outcomes) compared to the "cost" and/or "risk" of such screening. The study seemed to be well-designed and analyzed. What does that mean for you as a guy who wants to catch a prostate Ca early when it could be cured? Actually, it means very little, because the study deals with "population" risks/benefits.

The PSA is a simple blood test. It costs money (about $100 for the test plus some more for the doctor visit). A negative test doesn't absolutely exclude prostate Ca, but for all practical purposes it does exclude it. A high PSA (>5) level is suggestive of Ca, but could be due to relatively benign things like prostatic hypertrophy or a low level prostate infection. A really high level (say >20) is highly suggestive of Ca.

A high PSA may lead to invasive and potentially harmful procedures, like biopsy, and it's clear that subjecting everyone over 50 to PSA testing will lead to many arguably unecessary biopsies. It will also lead to lots of expensive testing and even risky diagnostic procedures, at least as far as the healthcare expense beancounters are concerned. But it is also true that such testing will, in a certain number of cases, allow for the detection of early stage asymptomatic and curable prostate Ca...For those "individuals" the routine PSA testing will be life-saving.

There's another angle to all this. Prostate Ca is fairly common in older men...the incidence increases with age, and the majority of men >75 years old will have cancerous cells in their prostates. Few will die from prostate Ca. I recall our US Senator from California, Alan Cranston, who basically escaped prosecution for his being involved in the Keating Five scandal because of his prostate Ca diagnosis...he lived for many years and died of something else. There was also that Libyan Lockerbie bomber terrorist who was recently paroled from a British prison because of his prostate Ca diagnosis...So far as I know the bastard is still alive and will, like Senator Cranston, die of "old age." This doesn't mean that prostate Ca is nothing to worry about. Prostate Ca is serious business. It is particularly serious when diagnosed in younger men, where it typically presents more aggressively than in older guys. And it is this younger population that will suffer from the conclusions of this study.

For the purposes of full disclosure, I am a physician. I was aware of this study's recommendations about routine PSA testing in "younger" men, but I chose to get tested when I turned 50. The result was negative. I plan to get tested every 5 years, rtegardless of symptoms, and if my PSA becomes elevated I'll procede accordingly.
I couldn't get that bolding out. I followed with this which is where we left off:
Good post and covers all the bases that we have been discussing. But it doesn't help me with the underlying dilemma: as an individual how do I balance the risk/reward? Your approach appears to rest on the intention to catch any possible cancer and treat ALL cancers. Or, at least, to do so at younger ages. The studies seem to me to be saying that overall the risks outweigh the rewards, i.e. you are individually better off risking a small chance of a bad cancer outcome to avoid a much higher chance of a bad unnecessary side effect of PSA testing/treatment. It is this choice of balance that is so difficult for many of us to sort out. Also, you don't address how (or if) the balance changes with age. For example, if I accept your premise for testing at younger ages what about when I am older. If I stayed low on the PSA scale into my mid 60s, 70s, 75... is there a point at which I should figure everybody starts getting CA at this point and treatment may not be worth pursuing (thus time to stop screening)? It seems to me that at bottom line this is not really a medical question that can be answered for us by a knowledgeable physician. It is more of a personal lifestyle question that includes evaluation of rapidly changing medical facts - I guess that often is the case with cancer. There are a lot of possible approaches to this risk/reward dilemma (test and treat at a relatively low PSA; test and treat only at a very high PSA; test and treat only with rapid acceleration; and possibly cut off testing at a given age). I would like to see more discussion about the impact of those alternatives and the risks/rewards involved.
Couldn't get that bold out either.

So, if you lasted this far, what do you think about how we should deal with this dilemma?
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Old 10-14-2011, 10:52 AM   #2
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So the previous threads we've had about this were not serious? I thought they were serious. In the thread Any New Info on PSA Screening?
TromboneAl gave links in the first post to our previous discussions. In post #112 of that thread, I gave this link,
Poor science underlies the USPSTF recommendation about PSA-based screening « THE "NEW" PROSTATE CANCER INFOLINK, to a discussion thread about the USPSTF report.

My opinion about the report is that it is confused. It takes lack of evidence of benefit to be evidence of lack of benefit. And even though the PSA test is effective, safe, and relatively cheap, it recommends against using it for screening because "it may lead to" other tests and treatments which are harmful and ill-advised. I think it's those other tests and treatments that we should be more careful about, rather than the PSA test.
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Old 10-14-2011, 11:02 AM   #3
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Quote:
Originally Posted by GregLee View Post
So the previous threads we've had about this were not serious? I thought they were serious. In the thread Any New Info on PSA Screening?
TromboneAl gave links in the first post to our previous discussions. In post #112 of that thread, I gave this link,
Poor science underlies the USPSTF recommendation about PSA-based screening « THE "NEW" PROSTATE CANCER INFOLINK, to a discussion thread about the USPSTF report.

My opinion about the report is that it is confused. It takes lack of evidence of benefit to be evidence of lack of benefit. And even though the PSA test is effective, safe, and relatively cheap, it recommends against using it for screening because "it may lead to" other tests and treatments which are harmful and ill-advised. I think it's those other tests and treatments that we should be more careful about, rather than the PSA test.
Sorry, my bad. I must have missed them. Maybe we can close this one. All I saw was the vitamin E thread and that one we were just having fun with.
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Old 10-14-2011, 11:13 AM   #4
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What do I think?

I'm grateful DH had/has his annual physicals including the PSA test. At 56 years old, his PSA was a 4. It was recommended he have a biopsy since his level had increased over time. I'm glad he did, because he had Stage 2 prostate cancer.

Hopefully the RT worked...if he didn't have the treatment he would die a painful death from this cancer.

He wasn't ready to 'hang it up' at the age of 56. He wants to live.
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Old 10-14-2011, 12:01 PM   #5
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I read the thread Greg Lee referenced and it is excellent. A much better place for my question. I will copy a couple of pieces from here and paste over there. If any admins are reading these, can you just delete this thread? Or close it and reference the other thread?
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Old 10-14-2011, 12:17 PM   #6
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I'm of the opinion that PSA by itself is less than useful except in the extreme case, where there's a high velocity, or sudden change in levels from year to year.

My PSA was 2.8 in 2005, with DRE showing a slightly enlarged prostate. Probably BPH, and I was put on Hytrin. Six years later, the PSA is bouncing around 3.2-3.4 the past couple of years. Not a big deal, but... DRE shows asymmetric enlargement, and a couple of hard spots on one lobe. Oh, and I can't urinate any more, so I have some new wardrobe accessories.. So, I'm undergoing treatments, and a cystoscopy and probably biopsies are in my future.

The PSA was the only negative indicator, and not very negative at that, as the level is consistently higher than average for someone my age, while just below the threshold that would normally bring on closer inspection.
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Old 10-14-2011, 12:43 PM   #7
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Probably BPH, and I was put on Hytrin.
I hadn't heard of Hytrin -- thanks for the reference. After a very high PSA, over 7, my doctor prescribed Flomax in 2006, but I didn't notice any effect, and I stopped taking it. Later, with PSA much lower but still high, a urologist diagnosed BPH and prescribed Avodart. I took that for almost a year, and the urologist said there was some prostate shrinkage. After I noticed some pain in my breasts, which is one of Avodart's listed side effects, I stopped the Avodart, and now am not taking anything for the BPH (which doesn't seem to be getting any worse). I'm getting a PSA every 6 months, and an exam from my urologist once a year.
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Old 10-14-2011, 12:58 PM   #8
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I had elevated PSA and an enlarged prostate so I had a very painful biopsy. They lost my biopsy samples, so I had another biopsy under general anesthetic. That was not painful, except that night I couldn't pee (very uncomfortable) and had to get a catheter inserted at the emergency room. That was removed the next day and things returned to normal. The results of the second biopsy were negative.

Not sure what we would have done without the PSA test. These days I might wait for a little more evidence, like high PSA for a year and a growing prostate or other symptoms, knowing the "costs" of the biopsy. Same thing if the biopsy turns out positive. Keep an eye on it for a year and see how agressive it looks. We still check my PSA yearly and it is lower, though probably more thanks to Avodart than getting healthier.
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Old 10-14-2011, 01:09 PM   #9
 
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Years ago I went to the urologist for an exam. My PSA was OK but in a manual exam the urologist felt abnormalities. I had a biopsy and 9 black spots (this is what the doctor called them) were removed. I was told I had a precursor for prostate cancer. Six months later I had to have another biopsy and more spots were removed. Since then everything has been fine. I go for an exam every 6 months.

The urologist and I have discussed the PSA test and he is a firm believer in them.
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Old 10-14-2011, 01:41 PM   #10
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Quote:
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I hadn't heard of Hytrin -- thanks for the reference. After a very high PSA, over 7, my doctor prescribed Flomax in 2006, but I didn't notice any effect, and I stopped taking it. Later, with PSA much lower but still high, a urologist diagnosed BPH and prescribed Avodart. I took that for almost a year, and the urologist said there was some prostate shrinkage. After I noticed some pain in my breasts, which is one of Avodart's listed side effects, I stopped the Avodart, and now am not taking anything for the BPH (which doesn't seem to be getting any worse). I'm getting a PSA every 6 months, and an exam from my urologist once a year.
Hytrin, or terazosin, is an alpha blocker like Flomax. There are some differences in side effects between Hytrin and Flomax, but they both do basically the same thing, relax smooth muscle tissue including the prostate and bladder neck, to try and improve urinary flow. I haven't had any side effects of any significance with generic terazosin, and since it is much cheaper than Flomax, I'll stick with it.

I'm also on finasteride, or Proscar, which like dutasteride or Avodart, is used to gradually shrink the prostate. It blocks the enzymes that convert testosterone to dihydrotestosterone. Lowering the level of dihydrotestosterone in turn causes a decrease in cell size and activity over several months. I wouldn't expect to see any improvement for 4-5 months, possibly a year. The effect isn't permanent, so if it works I'll be on this stuff for a long time.(This one is also a generic, from the fine laboratory of Dr. Reddy.)

While I'm waiting, I have my hose and plumbing kit.
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Old 10-14-2011, 02:35 PM   #11
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Quote:
Originally Posted by M Paquette

Hytrin, or terazosin, is an alpha blocker like Flomax. There are some differences in side effects between Hytrin and Flomax, but they both do basically the same thing, relax smooth muscle tissue including the prostate and bladder neck, to try and improve urinary flow. I haven't had any side effects of any significance with generic terazosin, and since it is much cheaper than Flomax, I'll stick with it.

I'm also on finasteride, or Proscar, which like dutasteride or Avodart, is used to gradually shrink the prostate. It blocks the enzymes that convert testosterone to dihydrotestosterone. Lowering the level of dihydrotestosterone in turn causes a decrease in cell size and activity over several months. I wouldn't expect to see any improvement for 4-5 months, possibly a year. The effect isn't permanent, so if it works I'll be on this stuff for a long time.(This one is also a generic, from the fine laboratory of Dr. Reddy.)

While I'm waiting, I have my hose and plumbing kit.
M Paquette, did the Proscar grow any hair on your head, like they say it does? Not that I have a receding hairline and wouldn't be concerned over such things.
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Old 10-14-2011, 03:46 PM   #12
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M Paquette, did the Proscar grow any hair on your head, like they say it does? Not that I have a receding hairline and wouldn't be concerned over such things.
Not yet, but that also takes months to appear. Perhaps I'll get a good response like this, and I can do the Trump ear-hair comb-over.



Although the way things are going, perhaps this look is more likely:
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