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Old 03-21-2009, 12:47 PM   #21
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Just a word of caution -- sometimes if a doc sees something that's probably OK but just a little bit out of line, he or she might not mention it directly to avoid alarming you, but may compensate by suggesting a bit sooner followup than usual. Maybe the eye doctor sees mild changes of glaucoma or it could be just normal variation (we are as different inside as we are outside). Or maybe the dentist saw mild periodontal disease, etc.

If in doubt, you can always ask, "Do you think it would be OK to wait two years (or whatever), if I call you right away with any problems?" The reply should help you understand their recommendation.
Interesting point - thanks Rich. Dentist is very happy with my gums,
usually doesn't even bother to measure the gaps (whatever that's
called). I'll ask the eye doctor for the pressure reading.
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Old 03-28-2009, 03:12 PM   #22
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I subscribe to Johns Hopkins Health Alerts newsletters, and received this one this week:

Johns Hopkins: Prostate Disorders on PSA controversy
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Old 03-28-2009, 03:47 PM   #23
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I subscribe to Johns Hopkins Health Alerts newsletters, and received this one this week:

Johns Hopkins: Prostate Disorders on PSA controversy
Dr. Carter is underestimating the downside, in my opinion. For every true positive result, you have 5 or 6 false-positives who are caused anxiety, pain, and rarely even serious complications.

To make matters more confusing, many of the true positives might have never needed treatment (many live for decades with stable small prostate cancers that never would have caused trouble). Yes, there is the occasional case who is a true positive and is cured from a disease which would have been fatal. The question is, whether that "save" is worth the price both in dollars and other negatives as noted above.

I do order the test often, but feel it is only right that the patient knows all of this going into it. Not an easy dilemma.
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Old 03-28-2009, 08:48 PM   #24
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Rich,

My Doc does both PSA and the "traditional" method. From what has been posted, it sounds as if nothing is "worth" doing from a risk/benefit/cost/etc. basis. So, do we just wait for "symptoms". The old "catch it in time" doesn't apply? What's a man to do?

Belt and suspenders guys want to know!
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Old 03-28-2009, 10:00 PM   #25
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Rich,

My Doc does both PSA and the "traditional" method. From what has been posted, it sounds as if nothing is "worth" doing from a risk/benefit/cost/etc. basis. So, do we just wait for "symptoms". The old "catch it in time" doesn't apply? What's a man to do?

Belt and suspenders guys want to know!
I guess my view is that there is no right or wrong answer in a general sense - each patient has to decide. My beef is with just ordering it with minimal discussion only to find you are faced with a borderline high reading, and no idea where to go from there (it's much harder to stop short at that point).

For every "catch it in time" scenario, there are 5 "catch it in time but it's a false alarm after biopsies" scenarios.

Some good questions to ask your doc: "what is the likelihood of prostate cancer if the result is 4-10?" and "what's involved with a prostate biopsy?" and "what's the likelihood of a false alarm positive result?"

For some, the PSA is the right strategy, and for many others it may not be.
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Old 03-28-2009, 10:07 PM   #26
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At age 50 I had a PSA test done at Megacorp and it came in at a 12. The company doctor recommended a biopsy. I had the biopsy. A beer can sized probe that shoots needles into your prostate while you watch it on a TV screen so you know when to yell OUCH! They took 8 samples making a pin cushion out of my prostate gland. Well, the test was negative and I never had another test level that high again. Now at age 61 I just tested at 3.4 after testing at 1.6 so my doctor wants to retest at 6 months. I would be very reluctant to have another biopsy and would probably need to see several years of elevated tests before making a decision.
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Old 03-28-2009, 10:56 PM   #27
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For some, the PSA is the right strategy, and for many others it may not be.
Thanks Rich, that helps a lot!

Just kidding. Seriously, I guess it partly comes down to luck. If you're one of the relatively few who get the aggressive kind, it would have been better to have the tests and follow up with biopsy. But, until they get a more specific test, you just have to go for the best comfort level - With a still OK PSA, I'm thinking I'd go for the biopsy if it suddenly jumped. But, push comes to shove - so to speak - I might change my mind - especially after reading Bikerdude's account.
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Old 03-29-2009, 07:25 AM   #28
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Just kidding. Seriously, I guess it partly comes down to luck. If you're one of the relatively few who get the aggressive kind, it would have been better to have the tests and follow up with biopsy. But, until they get a more specific test, you just have to go for the best comfort level - With a still OK PSA, I'm thinking I'd go for the biopsy if it suddenly jumped. But, push comes to shove - so to speak - I might change my mind - especially after reading Bikerdude's account.
I still think the poker or "game theory" metaphor works best to help people get a sense of the decision. It's like betting on a full house in a poker hand. You might win, you might lose, and no one can tell you what the "right" thing to do is. But most of the time you'd win. And when you lose, it doesn't mean you made the "wrong" decision, just that lady luck bailed out on you that time.
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Old 03-29-2009, 07:59 AM   #29
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My dear ol dad had a PSA test as part of his annual around 14 years ago or so. It was a little ove 4, doc did a biopsy, confirmed cancer, agressive type. Radical prostatectomy cured him but almost killed him (he bled a lot more than normal) and he still deals with mild incontinence. The cancer had not yet breached the capsule/shell around the prostate, but was more developed thant the biopsy showed just weeks before. I really fel that if the PSA test/annual physical had bee put off for 6 months, that my dear dad would not be with us.

So are there false alarms? Sure, but what percentage of the total # of men tested have a false high reading? What % of men who had a high reading also had prostate cancer? How about the aggresive "do something about this now!" variations, what % are they. ....and finally out of the total subjects tested, what is the ratio of "gotta do something" patients to "false positive" patients. I would bet the last ratio is pretty high...not even taking into account the "over 75 agegroup" due to the likelyhood that they will die with prostate cancer anway, but not die OF prostate cancer.

My position is that I don't think this issue should be considered lightly, especially after the profound outcomes it has had on our family.

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Old 03-29-2009, 08:57 AM   #30
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My dear ol dad had a PSA test as part of his annual around 14 years ago or so. It was a little ove 4, doc did a biopsy, confirmed cancer, agressive type. Radical prostatectomy cured him but almost killed him (he bled a lot more than normal) and he still deals with mild incontinence.
I think you hit on the real problem. The PSA is an imperfect indication of PC, but it does have some predictive value, expecially at higher levels, high velocities, etc. I don't think any of us would give a hoot about how good the PSA test was if there was a simple way of dealing with PC.

Suppose, hypothetically, there was a perfect test, it gave 100% correct results whether someone had PC or not. If someone were positive on such a test, there would still be the choice of living with a cancer that may not be what eventually killed him, or accepting a treatment that may leave him incontinent and/or impotent. That's the real problem, IMHO.

It would be good to have a test that, even if not perfect, could predict the type of cancer. In your dad's case, he was told it was the aggressive type, which made his choice a bit easier even if it had side effects. But what about someone told they have a low grade cancer? I don't know many urologists that would say "you have cancer, but let's not worry about it, because you'll probably die of something else." Almost surely they would recommend surgery or other active treatment. So, we have to deal with really bad choices.

There are alternate treatments to surgery, and they offer some hope. I have a friend who chose seed implants, was back to golf in a week, and so far has had no side effects after a couple of years -- but some radiation effects take longer to show up, and the history of implants is not as long as for surgery. And there are other implant patients who do suffer more immediate effects.
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Old 03-29-2009, 11:15 AM   #31
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It's odd to think that one might decline the test because one may not like the answer it gives. After all, there is nothing that says you must take any further action in the event of a high reading. Although that is easy for me to say in light of the events of this past week.

This thread started two days before my very first PSA test. Actually, I did not even know that it would be tested. It was just part of a battery of blood tests in anticipation of my 50th birthday checkup (I have never before had a regular checkup, but my young wife bugged me until I agreed to do it). I just got the results in the mail yesterday -- 1.07 on the PSA, so I guess I'm okay with that.

An analogous situation, however, may be my cholesterol results, which came in at 224 total, higher than the recommended 200. I have done some reading on the topic and I may adjust my diet somewhat (no more fettucine alfredo, for example), but I think it highly unlikely that I will take a statin, even if the doctor suggests it.
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Old 03-29-2009, 12:14 PM   #32
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It's odd to think that one might decline the test because one may not like the answer it gives. After all, there is nothing that says you must take any further action in the event of a high reading. Although that is easy for me to say in light of the events of this past week.
True in theory, but once faced with an abnormal result that has a 15-20% chance of being cancer, it is almost humanly impossible to do nothing. Trust me.

OTOH, deciding in a leisurely manner with full information whether to even have the test in the first place is a lot easier and may more accurately reflect your own values.
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Old 03-29-2009, 12:15 PM   #33
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It's odd to think that one might decline the test because one may not like the answer it gives.
I don't think "blissful ignorance" is considered a legitimate entry on a death certificate, but I bet it's pretty common.

My father went through the same "watchful waiting" mindset on his prostate-cancer diagnosis (both PSA & DRE) at age 66. He eventually relented after a few weeks (maybe felt some symptoms that he didn't mention?) and went for a biopsy. Good thing, too, since the tumor was stage IV. (He hadn't gone to a doctor in nearly a decade.) He's presumably happy to have gained the ensuing decade of longevity.

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I just got the results in the mail yesterday -- 1.07 on the PSA, so I guess I'm okay with that.
An analogous situation, however, may be my cholesterol results, which came in at 224 total, higher than the recommended 200. I have done some reading on the topic and I may adjust my diet somewhat (no more fettucine alfredo, for example), but I think it highly unlikely that I will take a statin, even if the doctor suggests it.
After years of being a nuke, I'm finally beginning to understand the distinction between "out of specification" and "requires corrective action". Heck, even nukes are learning to live with the phrase "cost effective". IMO some doctors have a way to go on this journey of enlightenment.
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Old 03-29-2009, 12:21 PM   #34
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True in theory, but once faced with an abnormal result that has a 15-20% chance of being cancer, it is almost humanly impossible to do nothing. Trust me.

OTOH, deciding in a leisurely manner with full information whether to even have the test in the first place is a lot easier and may more accurately reflect your own values.
Does the PSA reading get higher as the cancer progresses? The reason I ask is that I could see it being 5 and someone saying, "well, let's see if it goes higher or lower in six months and then I'll make a decision."
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Old 03-29-2009, 12:33 PM   #35
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I don't think "blissful ignorance" is considered a legitimate entry on a death certificate, but I bet it's pretty common.
I once heard that you cannot die of "old age" anymore in the USA. Some decades ago that particular cause of death was removed from the options a doctor could put on the death certificate.

Back to the thread topic. I have read it with interest. Since age 40 the PSA test has been a part of my annual company physical and it has always been extremely low so if I did have a PSA over 4 I would probably elect to have further tests such as a biopsy, given a sudden change in the results.

I'm off to see a urologist this week as I believe I have all the symptoms of BPH (enlarged prostate).
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Old 03-29-2009, 12:52 PM   #36
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It's odd to think that one might decline the test because one may not like the answer it gives. After all, there is nothing that says you must take any further action in the event of a high reading. Although that is easy for me to say in light of the events of this past week.
Except that the whole thread is about trying to deal with a situation in which the science seems to be indicating that the test may scare you into doing something that is not in your best interest. It is not that you don't want to hear the answer it is that the "answer" may be misleading.
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Old 03-29-2009, 01:03 PM   #37
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Except that the whole thread is about trying to deal with a situation in which the science seems to be indicating that the test may scare you into doing something that is not in your best interest. It is not that you don't want to hear the answer it is that the "answer" may be misleading.
I understand completely. I guess I just fall into the "more data is better" category and try to work on the "not being scared into doing something" side of the equation. But others feel differently I'm sure.
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Old 03-29-2009, 01:08 PM   #38
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Does the PSA reading get higher as the cancer progresses? The reason I ask is that I could see it being 5 and someone saying, "well, let's see if it goes higher or lower in six months and then I'll make a decision."
Yes. The 4-10 range is where the early cancer is to be found (along with a bunch of noncancer patients, as discussed).

Values over 10 are much more likely to indicate cancer, but the problem is that many of those are advanced and not curable even if they are asymptomatic (no survival value in diagnosing it sooner). Treating the advanced ones does not save lives and unless the patient has symptoms, does not improve the quality of life. In this case we are well out of the "screening" range on which this thread was focused.

Change over time (PSA "velocity") is one of several ways to try to see which abnormals are true and which are false. It is imperfect but is useful if the velocity is very high, just not sure if these are already not curable.
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Old 03-29-2009, 01:23 PM   #39
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... so if I did have a PSA over 4 I would probably elect to have further tests such as a biopsy, given a sudden change in the results.

I'm off to see a urologist this week as I believe I have all the symptoms of BPH (enlarged prostate).

I'm not a doctor but I understand that if you have BPH your PSA will probably be high, but from the PSA, not necessarily from PC. Rich?

Not to scare anyone, but some leading urologists, like Dr Catalona, are now saying that 2.5 should be the threshold.

"Dr. Catalona thought, “What’s the point of waiting for a biopsy until a PSA of 4 with men who have a PSA of over 2.5? A good majority is going to get to 4 and above in a few short years."
Importance of PSA 2.5 Threshold for Biopsy

I have an idea. Instead of all of this PSA noise, why don't they just remove our prostates as standard practice when we hit 40 and issue us diapers and viagra?
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Old 03-29-2009, 01:34 PM   #40
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I'm not a doctor but I understand that if you have BPH your PSA will probably be high, but from the PSA, not necessarily from PC. Rich?

Not to scare anyone, but some leading urologists, like Dr Catalona, are now saying that 2.5 should be the threshold.

"Dr. Catalona thought, “What’s the point of waiting for a biopsy until a PSA of 4 with men who have a PSA of over 2.5? A good majority is going to get to 4 and above in a few short years."
Importance of PSA 2.5 Threshold for Biopsy

I have an idea. Instead of all of this PSA noise, why don't they just remove our prostates as standard practice when we hit 40 and issue us diapers and viagra?
Yes, BPH and prostate infection will raise the PSA in the absence of cancer. For that matter, ejaculating within 48 hrs prior to testing can elevate the PSA a bit. <<insert your punchline here>>

Lowering the PSA cutoff to 2.5 will increase the sensitivity and lower the specificity. Translation: even more false positives (the cost for picking up a few more true positives).
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