PSA Test Found to Save Few Lives Over A 10 Year Period in Large Trial

[haha]

http://www.nytimes.com/2009/03/19/health/19cancer.html?em=&pagewanted=print

I have sometimes wondered what I would do if my PSA started up.

Ha

 

[Rich_by_the_Bay]

If you decide to follow your PSA levels, there is no benefit after age 75 or a life expectancy under 10 years. And ask your doctor about doing it every 2 years rather than every year before that (except in high risk populations such as a family history, African American, etc.). On the bright side, for screening the digital rectal exam has not been shown to be of value in saving lives.

It's an imperfect screening tool; a high percentage of patients in the 4-10 range are false positives, but undergo transrectal (yes, you heard that right) prostate biopsies.

I asked my doctor to not do it, but he did anyway. Thank goodness it was OK.

 

[FinallyRetired]

On the bright side, for screening the digital rectal exam has not been shown to be of value in saving lives.

Rich, I assume you meant "has been shown" to be of value instead of "has not been shown."

I had a PSA slightly over 4 a couple of years ago, was retested and it was below 4. I test every 6 months and it bounces around from the high 2's to the high 3's. I also told my doctor at the last checkup tp not take a PSA, because I was going to the caribbean for a few months and wanted to enjoy my time. Besides, there was nothing I would do in those few months even if it was high. When I get back I'll get another test and go from there. I hope they come out with a PC specific test soon, instead of the PSA that has so many false positives.

 

[JOHNNIE36]

If you decide to follow your PSA levels, there is no benefit after age 75 or a life expectancy under 10 years. And ask your doctor about doing it every 2 years rather than every year before that (except in high risk populations such as a family history, African American, etc.). On the bright side, for screening the digital rectal exam has not been shown to be of value in saving lives.

It's an imperfect screening tool; a high percentage of patients in the 4-10 range are false positives, but undergo transrectal (yes, you heard that right) prostate biopsies.

I asked my doctor to not do it, but he did anyway. Thank goodness it was OK.

Rich, not picking on you; but you are a physician. I'm asking just what the hell are we to believe anymore. I've been doing the PSA test and the digital exam for years and every thing is OK. PSA has always been about 1.0 and now I hear this doesn't mean anything? Guess I might as well forget colonoscopy too. It probably doesn't mean anything. Tell me whats going on in the medical profession. Can't believe anything you hear or read. It's getting to be a joke. Especially the prescription drug thing. I'm a Vioxx victim. Guess they all knew this caused heart atttacks and never disclosed it.

 

[Rich_by_the_Bay]

Rich, I assume you meant "has been shown" to be of value instead of "has not been shown."

No, I meant it as I posted: rectal exam has NOT been shown to have screening value.

Here's a layman's perspective and here is a technical handout for patients. Here's a typical evidence-based guideline.

Bottom line is that there is no evidence to support it. I suspect that by the time you feel a tumor on that exam, it is large enough to either have caused symptoms, or certainly to elevate the PSA markedly. Note: this refers to screening only, not evaluation of patients with symptoms or abnormal blood tests, and to those at standard risk.

 

[Nords]

Johnnie, my impression of PSAs is that if you've made it as far as you have then it just doesn't matter for you anymore.

I started doing PSAs & DREs in my low 40s since my father had been diagnosed with a stage IV tumor at the age of 66. He survived his radical prostatectomy and I've had a string of PSAs<1. Last year the clinician pointed out that I was still over 15 years away from the age at which my father was diagnosed, so I might as well relax until age 50 (for the colonoscopy/DRE super-sized value menu) and then only check it once every few years after that.

... but undergo transrectal (yes, you heard that right) prostate biopsies.
I asked my doctor to not do it, but he did anyway. Thank goodness it was OK.

What did he do-- sneak up behind you with the needle while you were bent over looking at something, or wait until you dozed off?

 

[FinallyRetired]

No, I meant it as I posted: rectal exam has NOT been shown to have screening value.

OIC. Thanks for the clarification and for those valuable links. From one of your links:

"Prostate cancer may be slow growing and may never advance or progress to cause significant disease or death. Treatment can cause both short- and long-term side effects (e.g., pain, urinary incontinence, and impotence)."

That's the problem in a nutshell. A high PSA opens the door to a tortuous path beginning with biopsies. If enough biopsies are done, I think eventually one will show something. Then comes the decision as to what to do about it. There are so many options, and no option is uniformly best, they all come with benefits and risks. And yet, in the end, the cancer may not have been significant to mortality.

One of my friends had a radical and it took him a year to get back to "normal," but now he is fairly certain he is cancer free. Another friend had seed implants and was playing golf in a week, but has to worry about it coming back (although the latest numbers I saw show that for at least 15 years the risk is the same as with a radical).

Having said all of that, it's a good thing that we are more conscious about this terrible disease, and correct information is always good, even if it places more of a burden on each of us to participate with our doctors in making informed decisions.

What did he do-- sneak up behind you with the needle while you were bent over looking at something, or wait until you dozed off?

Ah, memories of basic training.

 

[Rich_by_the_Bay]

Rich, not picking on you; but you are a physician. I'm asking just what the hell are we to believe anymore. I've been doing the PSA test and the digital exam for years and every thing is OK. PSA has always been about 1.0 and now I hear this doesn't mean anything? Guess I might as well forget colonoscopy too. It probably doesn't mean anything. Tell me whats going on in the medical profession. Can't believe anything you hear or read. It's getting to be a joke. Especially the prescription drug thing. I'm a Vioxx victim. Guess they all knew this caused heart atttacks and never disclosed it.

Your reaction is not unjustified. The trick is to think in terms of probabilities, not certainties. In the case of any "health recommendation" relating to lifestyle, prevention, nutrition, etc. there are and always will be limitations in the evidence.

I think of it like this: if I'm holding a full house it is probably wise to bet on it. Won't always win, and sometimes will get creamed but the decision to bet is the right one based on available data and your "read" of the scenario.

PSA screening? For me, more like 2 pair. Flu shot? 4 of a kind. Colonoscopy? Maybe a straight. These are based on the costs (including discomfort and finances), your personal values (at age 80 maybe you don't care to undergo a given procedure).

Cynicism is understandable but shouldn't drive your decision. All in all these broad medical recommendations have done well by society, just not all the time. If you're lucky you've got a primary doctor who can frame the issues with you; I spend a lot of time doing that with my patients, handouts and all.

 

[Rich_by_the_Bay]

What did he do-- sneak up behind you with the needle while you were bent over looking at something, or wait until you dozed off?

Oops, I meant the PSA, not the biopsy.

 

[Rich_by_the_Bay]

That's the problem in a nutshell. A high PSA opens the door to a tortuous path beginning with biopsies. If enough biopsies are done, I think eventually one will show something. Then comes the decision as to what to do about it.

Agree. And an important issue is all those (retrospectively) false positive PSAs leading to biopsies: a small percentage of biopsies are complicated by bleeding, sepsis and rarely even death, as I have seen in a handful of men over the decades. Complicated.

Over time, there should be a better version of the PSA that will make it more accurate. Meantime, we muddle along not quite sure what the best apporach is.

 

[donheff]

I read about this yesterday and vowed to tell my doctor not to do PSA tests anymore - sounds like the treatment can be worse than the problem at a 50:1 ratio. Then I heard what sounded like a reasonable expert on McNeil Lehrer. He confirmed what everybody here is saying but added a few other wrinkles. He pointed out that diagnosis and treatment is rapidly changing. There are two forms of prostate cancer - agressive and slow. Most are slow and like Rich says not worth going after if you are getting up in the years. The aggressive version is a different matter. The problem is the guy didn't answer what percent of cancers are the aggressive version or whether there is any easy way to identify them. If the TR biopsy is the only way to find out, it seems like you still risk all the nasty side effects for a 50:1 chance of helping yourself.

It seems to me the medical community needs to come up with some guidelines for doing the test. Or at least honoring a patient's request not to do it -- a request RIT's doctor refused to honor. Right now, absent new facts to sway me, I would choose to ignore an elevated PSA. But if my doctor insists on telling me what it is then I suffer from doubt. If I have already decided to forgo biopsy I don't want to hear the questionable info.

 

[FinallyRetired]

It seems to me the medical community needs to come up with some guidelines for doing the test. Or at least honoring a patient's request not to do it -- a request RIT's doctor refused to honor. Right now, absent new facts to sway me, I would choose to ignore an elevated PSA. But if my doctor insists on telling me what it is then I suffer from doubt. If I have already decided to forgo biopsy I don't want to hear the questionable info.

Donheff, here is another issue. Just having a high PSA (above 4), even if you have a negative biopsy, is enough for some life insurance companies to deny coverage, or for health insurance to include that as a pre-existing condition. It sucks.

 

[donheff]

Donheff, here is another issue. Just having a high PSA (above 4), even if you have a negative biopsy, is enough for some life insurance companies to deny coverage, or for health insurance to include that as a pre-existing condition. It sucks.

I hadn't thought about that. A valueless test cited to deny you insurance due to an unconfirmed preexisting condition. It would seem patients should have the right to refuse to allow labs to run the test.

 

[Rich_by_the_Bay]

Right now, absent new facts to sway me, I would choose to ignore an elevated PSA. But if my doctor insists on telling me what it is then I suffer from doubt. If I have already decided to forgo biopsy I don't want to hear the questionable info.

We are talking about results in the range of 4-10. The upper range and above are much more compelling and predictive of cancer though it may be the slow-growing kind.

My advice is to discuss it with the ordering physician who is in a position to compare it to previous levels (PSA "velocity"), knows your risk profile, and can help interpret the actual score (not just "normal/abnormal." If you decide not to have it, all the implications should be open and understood.

 

[Martha]

PSA screening? For me, more like 2 pair. Flu shot? 4 of a kind. Colonoscopy? Maybe a straight. These are based on the costs (including discomfort and finances), your personal values (at age 80 maybe you don't care to undergo a given procedure).

So what is a royal flush? Blood pressure screening? Stepping on the scale?

 

[Rich_by_the_Bay]

So what is a royal flush? Blood pressure screening? Stepping on the scale?

Hmm.. It's a short list as far as testing, really (though I don't need a royal flush to place my bet).

Most practices do far more diagnostic testing than are recommended by most scientific panels - not because they are advised against, but mostly because panels don't advise stuff for which there is inadequate evidence (recognizing that some may some day turn out to be wise).

Among my basic screening tests (ones I advise routinely for healthy patients in the right age and gender groups):

• Lipids every 5 years
• Pap every 2 years or so
• Blood pressure every couple of years
• Colonoscopy every 10, at least for a baseline
• Mammography (though this is a complicated one)
• PSA if patient desires after good coaching
• Eye exams every couple of years for the older patient
• Immunizations: tetanus, pertussis, flu, zoster; maybe pneumonia, hep b if risks
• HIV if risk exposure
• Lifestyle screening and counselling

Probably forgetting a few.

And there is something helpful and reassuring about the occasional office visit so the doc and patient learn each other's baseline style, drama level, and leanings.

 

[Dawg52]

Hmm.. It's a short list as far as testing, really (though I don't need a royal flush to place my bet).

Most practices do far more diagnostic testing than are recommended by most scientific panels - not because they are advised against, but mostly because panels don't advise stuff for which there is inadequate evidence (recognizing that some may some day turn out to be wise).

Among my basic screening tests (ones I advise routinely for healthy patients in the right age and gender groups):

• Lipids every 5 years
• Pap every 2 years or so
• Blood pressure every couple of years
• Colonoscopy every 10, at least for a baseline
• Mammography (though this is a complicated one)
• PSA if patient desires after good coaching
• Eye exams every couple of years for the older patient
• Immunizations: tetanus, pertussis, flu, zoster; maybe pneumonia, hep b if risks
• HIV if risk exposure
• Lifestyle screening and counselling

Probably forgetting a few.

And there is something helpful and reassuring about the occasional office visit so the doc and patient learn each other's baseline style, drama level, and leanings.

I'm glad the colon one is every 10 years. The prep sucks and my insurance only pays 100% every 10 years anyway.

 

[RustyShackleford]

[*]Eye exams every couple of years for the older patient

It's funny, I've noticed a 2-to-1 ration between the frequency of
various exams recommended by providers of those services versus
what is recommended by less biased sources (like Rich).

My eye doctor wants to see me every year (I wear no corrective
devices other than cheapo reading glasses). I read here and elsewhere
that every 2 years is fine.

My dentist (like virtually all) wants to see me every six months. I've
read several places that once a year is fine.

 

[Rich_by_the_Bay]

It's funny, I've noticed a 2-to-1 ration between the frequency of various exams recommended by providers of those services versus what is recommended by less biased sources (like Rich).

My eye doctor wants to see me every year (I wear no corrective
devices other than cheapo reading glasses). I read here and elsewhere
that every 2 years is fine.

My dentist (like virtually all) wants to see me every six months. I've
read several places that once a year is fine.

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.

 

[Alan]

Interesting thread. One concern I have about screening too frequently is that the Docs may be doing it to cover themselves in case they miss something. How many of them get sued I wonder if a patient of their's gets cancer (or whatever) and blames the Doc for not catching it with a screening test that was not frequent enough?

 

[RustyShackleford]

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.

 

[FinallyRetired]

I subscribe to Johns Hopkins Health Alerts newsletters, and received this one this week:

Johns Hopkins: Prostate Disorders on PSA controversy

 

[Rich_by_the_Bay]

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.

 

[Koolau]

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!

 

[Rich_by_the_Bay]

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.