Prostate Concerns - PSA Results

[Ol_Rancher]

I am 60 years old and have an enlarged prostate. I get a PSA test and a DRE (digital rectal exam) yearly each December.

My PSAs are well below the levels that were used in the past to indicate a concern. Now however the recent news about the 'PSA Velocity' has me concerned.

My past yearly PSA results in one year increments:
0.2
0.5
1.2

Although the levels are quite low the rate of change seems to be expotential. Tumor growth is also expotential.

this year's test is about 6 weeks away. The past DREs indicated that my prostate was enlarged but 'smooth'

According to my net searches -

In individuals with pre-clinical prostate cancer, there is an accelerated increase in serum PSA levels, beginning 7 to 9 years prior to diagnosis

Men with prostate cancer whose PSA level increased by more than 2.0 ng per milliliter during the year before the diagnosis of prostate cancer have a higher risk of death from prostate cancer

PSA velocity 10 to 15 years before a cancer was diagnosed was linked to survival 25 years later. Specifically, patients with a lower PSA velocity had a 92 percent survival rate, but patients with a higher PSA velocity had a 54 percent survival rate

.A man can have prostate cancer and still have a PSA level in the “normal” range. Approximately 25% of men who are diagnosed with prostate cancer have a PSA level below 4.0. In addition, only 25% of men with a PSA level of 4–10 are found to have prostate cancer. With a PSA level exceeding 10, this rate jumps to approximately 65%.

The physician will be checking for hardness of the prostate or for irregular shapes or bumps extending from the prostate – all of which may indicate a problem. The DRE is particularly useful because the PSA test may miss up to 25% of cancers, and the DRE may catch some of these.

PSA tests are used to screen men for prostate cancer, but they're imprecise. Too much PSA, or prostate-specific antigen, in a man's blood can indicate that he has either a benign enlarged prostate or cancer. Only a biopsy can tell the difference.
It's not even clear when is the best time to do a biopsy.

Some men have cancer despite a "normal" PSA count of 4 or below. Yet routinely biopsying men with low PSA would worsen another problem, overdiagnosis. Many specialists say too many men today are undergoing side effect-prone treatment for tumors too small and slow-growing to ever threaten their lives.

I plan to hve my next exam after the holidays to avoid having my concern become a distraction. I will post my next PSA results.

 

[Rich_by_the_Bay]

There is a large and credible group of researchers and decision analysts who question the value of the PSA as a screening test altogether. That is, there are enough false positives (who end up getting biopsied anyhow) and false negatives that the overall impact on a population may not be favorable, in the aggregate. It's a tough one to decide about.

Course, normal PSAs go up with each passing year in the absence of cancer. Only about 30% of men with PSAs over 4.0 have prostate cancer, though that number is linear as you get higher and higher levels.

Glad yours are in the normal range.

 

[Martha]

There was an article in the WSJ in the last week on the PSA testing issue. Some researchers are saying that testing starting at age 40 is a good idea, to get a feeling for your own baseline levels and to watch carefully if there are rapid increases.

 

[Dawg52]

There is a large and credible group of researchers and decision analysts who question the value of the PSA as a screening test altogether. That is, there are enough false positives (who end up getting biopsied anyhow) and false negatives that the overall impact on a population may not be favorable, in the aggregate. It's a tough one to decide about.

10 years ago my PSA number came in at around 2.4. May have been my first test. Anyway the doc started hinting around at a biopsy but decided to wait 3 months and do the test again. Next time the number was .8. It's been below 1 ever since. My current doc says he firmly believes the finger wave is a must and not to rely on the PSA test. I sure hate the manual test though.

 

[REWahoo]

My current doc says he firmly believes the finger wave is a must and not to rely on the PSA test. I sure hate the manual test though.

Next time you have the test ask your doc to use two fingers...butt only if you want a second opinion.

 

[MikeD]

I sure hate the manual test though.

The first time I had that test I drew in my breath so sharply from surprise that my internist, who I had known for 20 years, said "Wow, you wouldn't make a very good homosexual!"

Mike D.

 

[Rich_by_the_Bay]

The first time I had that test I drew in my breath so sharply from surprise that my internist, who I had known for 20 years, said "Wow, you wouldn't make a very good homosexual!"

Once had a patient (also a casual friend) turn around and look at me after I performed a procto (before the days of fiberoptics) and say, "Does this mean we're engaged?"

 

[Nords]

Welcome back, Ol' Rancher, but man what a way to restart your subscription! I saw that article and I've been meaning to dig out the old PSAs for comparison.

My father skipped his routine health exams for 10 years. When he finally visited a doctor for an unrelated problem, the GP insisted on running a full line of blood tests (to my father's grudging acceptance). I think at that point Dad's PSA popped at double digits and his surgery was a month later-- stage IV.

Sooooo... the annual PSA & exam seems well worth it now. But I put more credibility in the exam than in the PSA trend.

 

[Rich_by_the_Bay]

Sooooo... the annual PSA & exam seems well worth it now. But I put more credibility in the exam than in the PSA trend.

No, alas. The digital exam has not been shown to save or prolong lives from prostate cancer. It tends to detect more advanced cancers (where additional delay is not that critical in terms of survival - cat's out of the bag) and usually misses early disease (where intervention might have more impact).

We really need a better blood test, and there are more specific ones on the horizon so within a year or two I expect a decent test will be available.

For screening purposes, the sensitivity and, to a lesser extent, specificity of a test has to be very, very high since by definition the prevalence of the disease in question is low in the screening population.

 

[Nords]

No, alas. The digital exam has not been shown to save or prolong lives from prostate cancer. It tends to detect more advanced cancers (where additional delay is not that critical in terms of survival - cat's out of the bag) and usually misses early disease (where intervention might have more impact).

So both tests are equally useless? Where's my motivation?!?

Next month when the doctor's busy with his fingers I'm going to have to query his depth (so to speak) of knowledge on evidence-based medicine...

 

[Rich_by_the_Bay]

So both tests are equally useless? Where's my motivation?!?

Next month when the doctor's busy with his fingers I'm going to have to query his depth (so to speak) of knowledge on evidence-based medicine...

Uh, oh. I'm in trouble now.

No, the tests are not useless. They just entail a cost which may or may not justify the benefits for all men.

Prostate screening is controversial and the most prestigious consensus panels (and those without a secondary agenda) advise docs to discuss all this with the patients, and let them decide. If you proceed, you should be prepared to undergo prostate biopsy if it's positive, knowing that on average, 7 of 10 such biopsies will be negative (including a few missed cancers), and that there is a small but not trivial risk to the biopsy. Not to mention that the biopsy procedure is, well, unappealing.

Everyone has an anecdote about someone whose life was saved by a routine PSA or digital exam. There are many such cases. The question is, to generate one such case, how many healthy men must undergo unnecessary biopsies with small but predictable complications, cost and discomfort? And how many men treated based on a PSA detection would have done just fine without treatment, and died of something unrelated 10 years later (many prostate cancers remain localized for decades)?

I don't have the answers (no one does), but I think I have the right questions. It's confusing stuff and the best studies so far are nondefinitive. Hopefully more precise tests will be available soon.

 

[Corporateburnout]

Uh, oh. I'm in trouble now.

No, the tests are not useless. They just entail a cost which may or may not justify the benefits for all men.

Prostate screening is controversial and the most prestigious consensus panels (and those without a secondary agenda) advise docs to discuss all this with the patients, and let them decide. If you proceed, you should be prepared to undergo prostate biopsy if it's positive, knowing that on average, 7 of 10 such biopsies will be negative (including a few missed cancers), and that there is a small but not trivial risk to the biopsy. Not to mention that the biopsy procedure is, well, unappealing.

Everyone has an anecdote about someone whose life was saved by a routine PSA or digital exam. There are many such cases. The question is, to generate one such case, how many healthy men must undergo unnecessary biopsies with small but predictable complications, cost and discomfort? And how many men treated based on a PSA detection would have done just fine without treatment, and died of something unrelated 10 years later (many prostate cancers remain localized for decades)?

I don't have the answers (no one does), but I think I have the right questions. It's confusing stuff and the best studies so far are nondefinitive. Hopefully more precise tests will be available soon.

My brother had an infection that required hospitalization for a few days from a biopsy. Unfortunately for him it turned out to be cancerous and he is undergoing a surgery tomorrow. He is 59 years old and his urologist recommended the procedure because of his relative young age.

 

[heyyou]

The next door neighbor had one of those slow growing tumors. He had a newer procedure using three gold "seeds" that are planted to guide precision radiation.
One of my customers had his colon pierced by prostate radiation. After surviving the infection, he wore a colostomy bag for the rest of his life. He couldn't even go fishing but he kept the boat for the memories. His life was better than dying, but the joy was gone.

 

[Mr._johngalt]

The next door neighbor had one of those slow growing tumors. He had a newer procedure using three gold "seeds" that are planted to guide precision radiation.
One of my customers had his colon pierced by prostate radiation. After surviving the infection, he wore a colostomy bag for the rest of his life. He couldn't even go fishing but he kept the boat for the memories. His life was better than dying, but the joy was gone.

My Dad (89) says "stay away from all doctors" and means it.
I try to follow his example. Of course it's easier for him
(to stake out that position) as he has already beat the odds.

JG

 

[kcowan]

My Dad (89) says "stay away from all doctors" and means it.
I try to follow his example. Of course it's easier for him
(to stake out that position) as he has already beat the odds.

JG

My MIL refused all blood tests and stopped taking her meds a year ago. So far so good. OTOH she is 91 so she says Que Sera Sera. The cure was worse than the disease! Dad never took any meds and lasted until 95. Daily aspirin might have extended his life by a couple of years (stroke) but he was ready to go.

I get the DRE and PSA annually but I know the problems with PSA.

 

[azanon]

I had one digital prostrate examination, and I remeber it taking a good two days before i felt like i fully went back together. Two days of feeling violated was not fun.

 

[rs0460a]

Just to add my "story" to the thread...

My PSA came out "abnormal" about 3+ years ago. Digital (and not computer!) exam showed an enlarged gland, but at my age at that time (mid50's) could be considered "typical".

At the time, I had a concern since prostrate cancer is one of those items that falls within the scope of Agent Orange (AO) exposure that I was already declared "disabled" for my diabetes (not in my family - declared due to my AO exposure in Nam). For those of you that may be having the same situation, here's a link:

http://www.vba.va.gov/bln/21/Benefits/Herbicide/AOno1.htm

Anyway, I had the biopsy (ugh!) done. At the same time, the practice wanted me to participate in a study concerning a new "super drug" (Vioxx) that was to help in the situation.

As part of the study, I had to go through a full work-up, which included another PSA. Guess what? That PSA showed as normal (and after going through the biopsy..) Anyway, you know the story about Vioxx, so it's good that I didn't "participate".

Anyway, after being totally "disgusted" with the entire ordeal, I'm going to have the "digital" after I get my annual PSA (sometime in December).

Like I said - no information here; just telling my story to add to the thread.

Damn - it's a bitch getting old : : :

- Ron

 

[Nords]

Damn - it's a bitch getting old : : :
- Ron

Still better than the alternatives-- especially considering your former work environments!

 

[bosco]

I had one digital prostrate examination, and I remeber it taking a good two days before i felt like i fully went back together. Two days of feeling violated was not fun.

next time, try an analog exam....they're more gentle

 

[macdaddy]

My roommate's grandfather had 8 prostate biopsies after his PSA came up super elevated, but they never found any cancer.

 

[johnlw]

I'll add my story.

When I was 43, I had a physical. The doctor did a digital rectal exam, and man, it hurt pretty bad.

A few weeks later, I developed a perianal abscess (an infection right near my sphincter) that required surgery. The incision from the surgery has to stay open and heal from the inside out. It took 3 months to totally heal.

The doctor said the abscess is caused by a gland inside the anus becoming infected or blocked. I have always wondered if that examination had something to do with it...

John

 

[Ol_Rancher]

In reply to an earlier post on radiation treatment.

According to a Stanford lecture on the Research Channel (satellite TV):

The radiation treatment in which radioactive seeds are to be planted is such that an array of 'seeds' are implanted across the inside of the prostate gland, no longer in isolation or a cluster to treat just one tumor. In the mid '80s and on to the late 90s the typical array used six such seeds. Now the norm is to implant twelve of them and in some cases up to sixteen seeds.

Usually a prostate tumor is not alone but one of several, sometimes quite small. It is thought that a lower survival rate in those decades was attributable to this. Also, planting of the seeds is an art and often the array may leave some 'cold spots' (areas not near a seed) due to a bit of deformation of the enlarged gland. The upper rear of the gland wall is easier to plant the seeds but the lower front can be a challange which may account for some statistical differences in outcomes.

Biopsies have similar problems so now the Stanford clinic takes not four but six or more tissue samples but still can miss a small tumor.

The use of field radiation has its challenges also. Often the rectum walls can be scorched.

The use of cyberknife with its external beams is a good option for a specific target but some clinics with a cyberknife may not have a prostate cancer program for it. The advantage of cyberknife where ever it is used on a target, is that it has a 1 mm margin accuracy as opposed to a 3 - 4 mm for other external beam devices. It also can fire beams from dozens of angles greatly reducing collateral damage (the sum of the beams on the target equals the destructive energy). Irregular tumors can be better targeted too. Rather than layering a series of target intersecting spheres on a tumor, some curvalinear small fields are possible. Finally, the cyberknife can compensate for breathing and other reflexive body movements

MD Anderson is spending tens of millions on a proton beam machine rather than go with the cyberknife. It should allow the beam pathways to be safe and penetrate to what are currently untreatable tumors. I would expect a backlog of proton beam treatment procedures for children's cancers, most of which are in the brain and it is ex[ected that the machine will offer hope to many of them.

My exam will be on Jan. 4

I will post the results and share any decision making process.

 

[Ol_Rancher]

PSA update. After reviewing the PSA results of the last few years that were rising at an expotential rate (see 1st post in thread) my general practioner doctor and I decided that if the results were at or above a 2 then a biopsy would be prudent.

The PSA was 0.3 a real drop. I will have another exam in six months rather than wait a year. I am not ready to accept the results as definitive. Perhaps the enlarged prostate was responsible for the increasing numbers generated by a surface area increasing thus producing more of the protein markers measured by the test.

I do feel much better. I was dreading the logistics of exams, scans, doctor visits, and treatments more than the accompanying prognosis. I really did not want to drive to a city from the ranch.

 

[REWahoo]

Congrats on the new test results. Must be a big relief to see them move in the right direction.

 

[Nords]

Good news, Rancher. Here's to more boring PSA test results that are too low to be readily detectible...

Must be a big relief to see them move in the right direction.

We're still talking about the PSA tests, right?