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

[Rich_by_the_Bay]

Maybe the PSA test only saves a small percentage of lives, but if that life is yours, it saved 100%. Three years ago an annual PSA test showed that my PSA had moved up significantly from the prior year. I had a biopsy that showed cancer. My decision was to be treated with radiation and seed implants. I don't know if my cancer would have killed me or not, but I sure rest easier now that I know I am free of it. Why would anyone take even a small risk when such a simple testing is available?

Because you might end up as the guy who died from complications of a biopsy (e.g. sepsis) but without prostate cancer. You die from a failed preventive strategy.

I am very glad the whole thing fell into place for you. My only point is that this is a strategy question which individual anecdote probably won't solve. You are right: if you are the one, the salvage rate is 100%. From a public health perspective, we have to consider the other 99%, too.

Glad you came out well as a survivor, though.

 

[bluescat]

Rich: We know that tens of thousands of men die each year of prostate cancer. Can you tell me how many die of "sepis" from the biopsy procedure. Thanks!!

 

[Rich_by_the_Bay]

Rich: We know that tens of thousands of men die each year of prostate cancer. Can you tell me how many die of "sepis" from the biopsy procedure. Thanks!!

It's under 1% if I recall, but I think you are seeking the wrong denominator.

What my comments address is Joe Sixpack with no symptoms of prostate disease who gets a PSA routinely as part of his check-up. About 2.9% of men will die of prostate cancer over their lives -- the other 97.1% will not, so for every 100 men screened for prostate cancer, only 2.9 even have a chance of benefitting from screening (and many won't). The other 97.1% have no chance of improved survival, yet are subject to the concerns mentioned above.

Biopsy side effects include sepsis (maybe 1%), severe pain (25%), anxiety, bleeding from the urethra (23 percent longer than three days), fever (3.5 percent) and rectal bleeding (1.3 percent). Fewer than 1 percent developed urinary retention or required hospitalization as well as sepsis.

Just how many innocent bystanders is it worth harming in order to find one potential "winner?" I don't know, kind of a societal decision. We are at 32:1 now (probably much higher, since not all who are diagnosed from screeing actually benefit from treatments), and society isn't sure if this is a good strategy.

Here are some numbers from UptoDate, a professional evidence source:

"Evidence from randomized trials — There are currently no convincing data from randomized, controlled trials of screening that show benefits on morbidity and mortality.


One randomized trial of screening for prostate cancer reported positive findings, but the data analysis was flawed. In this population-based study in Quebec, 46,193 men aged 45 to 80 years identified from electoral records were randomly assigned to screening with prostate specific antigen (PSA) and digital rectal examination (DRE) versus no screening [54]. In an analysis that excluded the 77 percent of men in the screening arm who declined screening and excluded the 6.5 percent of men in the control group who were screened, the prostate cancer mortality rate in men undergoing screening was reported to be 67.1 percent lower than in the control group. When the data were evaluated by a more appropriate intention-to-screen analysis, there were no mortality differences between the two groups (4.6 versus 4.8 deaths per 1000 persons, respectively). Additionally, the results suggesting benefit seemed biologically implausible, since the survival benefit became apparent within only three years, a very short time for a screening program to be effective given the long lead time for prostate cancer.
Two large randomized screening trials are currently underway,... These studies, which plan to pool results, should have sufficient power and follow-up duration to determine the efficacy of screening. Preliminary reports from the ERSPC show effects of screening on detection rates and stage of disease at detectionbut effects on morbidity and mortality are still unknown; results from both trials will not be available for several more years."
​

Sorry for the wordy answer - hope it helps clarify my points.

 

[bluescat]

Rich: I don't believe that PSA screening is going to harm "Joe Sixpack". I believe it would be the inept physician that orders a biopsy without making an effort to confirm his suspicions with at least some of the following: "Positive DRE, Free PSA test, PAP test, PSA velocity evaluation and PSMA test. As you have stated some PCa's are rather benign, but on the other hand some are very aggressive and deadly, and the only way to find out which one you have, is to biopsy.
In regard to the studies you presented. It is my "opinion" that a study can be used to prove just about any position you wish to take.

 

[Gumby]

Bluescat:

Welcome to the board. Start a new thread in the "Hi, I am" section and tell us a little bit about yourself.

Best wishes,

Gumby

 

[Nords]

Rich: I don't believe that PSA screening is going to harm "Joe Sixpack". I believe it would be the inept physician that orders a biopsy without making an effort to confirm his suspicions with at least some of the following:

Well, paraphrasing Will Rogers, the solution is straightforward. Only use "ept" physicians. If they're inept then don't use them.

 

[bluescat]

Nords: I agree with you and Will 100%. Unfortunately, you sometimes don't find out about a DR.s "eptness" until it's too late

 

[bluescat]

Bluescat:

Welcome to the board. Start a new thread in the "Hi, I am" section and tell us a little bit about yourself.

Best wishes,

Gumby

Hi Gumby: I'd rather not, I'm just a lurker here (4 years, I think). I am however, a PCa survivor, 8 years, of hard fighting. I just received my "first ever" below 1.0, PSA result. I owe my life to PSA screening, and hate to see bad information being passed on to other men. I probably won't post on any other subject, but if I do I will start the thread you asked me to.

 

[Rich_by_the_Bay]

Finally had a minute to retrieve this article - nice summary of the difficult issues surrounding PSA screening. Good reading for those who want to make a balanced and well-informed decision together with their doc.

The USPSTF is a consensus panel of highly respected content experts, statisticians, and decision analysts who do exhaustive analyses of the current evidence. What is nice about their recommendations is that they are able to say "we don't know" when applicable.

 

[Nords]

Nords: I agree with you and Will 100%. Unfortunately, you sometimes don't find out about a DR.s "eptness" until it's too late

The point of my sarcasm is that a patient has to be informed about the issues and the risks. Doctors have to know a lot about everything but patients can attempt to become experts at one narrow subject-- themselves and their symptoms. Patients also have to ask questions, get second opinions, and not just blindly comply with the "They're the doctors, they're in charge" attitude. The responsibility rests at least as much with the patient as with the doctor.

Don't even get me started on the subject of reconstructive knee surgery.

 

[bluescat]

OH, I didn't realize you were being sarcastic. I guess I'm becoming a little naive in my old age. And I agree with you again 100%. Each patient has to take charge of his own outcome. But it would be hard to take charge agains PCa, if you didn't know you had it, and you won't know you have it, until your screened.

 

[bluescat]

What is nice about their recommendations is that they are able to say "we don't know" when applicable.

Thanks for posting the article, Rich. Their recomendation is what jumps out at you:

Recommendations:​

Current evidence is insufficient to assess the
balance of benefits and harms of screening for prostate cancer in
men younger than age 75 years (I statement).
Do not screen for prostate cancer in men age 75 years or older​

(Grade D recommendation

 

[FinallyRetired]

Finally had a minute to retrieve this article - nice summary of the difficult issues surrounding PSA screening. Good reading for those who want to make a balanced and well-informed decision together with their doc.

Rich
I appreciate your posting this type of article. I have a question about the following statement in the article:

"In men younger than age 75 years, the USPSTF found inadequate evidence to determine whether treatment for prostate cancer detected by screening improves health outcomes compared with treatment after clinical detection."​

​

How is PCa clinically detected? I thought it gave no symptoms until it had metastasized to the bones, etc, at which point it was very difficult to treat. But the article seems to indicate that treating it after it's found from screening (when there's a good chance it's still contained) hasn't been shown to be better than treating it after clinical detection. Seems puzzling.​

 

[Rich_by_the_Bay]

How is PCa clinically detected? I thought it gave no symptoms until it had metastasized to the bones, etc, at which point it was very difficult to treat.​

It is occasionally detected by a hard nodule or irregularity on digital exam (I have picked up a few such patients over the years), by blood in the urine, or by symptoms similar to those of benign prostate problems (weak stream, hesitancy, difficulty initiating urination, etc. which progress and/or don't respond to treatment.

You are right in that the outcomes between the two types (PSA-detected v. clinically detected) are not as different as you might expect. The reasons are not entirely known, but may relate to the fact that many prostate cancers are very slow growing and really never cause problems even when advanced; there are measures to slow down even some advanced cases (Lupron and other hormonal measures) so even many advanced patients live for many good-quality years.

Unfortunately there are still an unfortunate number of patients with very aggressive disease (measured by a Gleason Score, roughly a measure of how aggressive the tumor cells are). They do less well no matter how the tumor is detected. So in the end, the benefit of screening is less dramatic than you might have thought, and thus the potential harm of screening (including to the false alarm cases which vastly outnumber actual cases) must be taken into consideration when determining your preferred screening strategy.

• Best case: no symptoms, normal PSA (most)
• Best save: no symptoms, slightly abnormal PSA, higher grade Gleason Score, cured by surgery or radiation, a true "save" (occasional)
• Little added value: elevated PSA, normal biopsies but no complications except anxiety and cost (fairly common)
• Worst case: no symptoms, elevated PSA, complications from biopsy, no cancer detected (infrequent but not rare)
• Bad: detected on PSA but already advanced, with same outcome as if the patient had simply waited for first symptoms (longer time to worry about it due to early detection)

​