PSA: on PSA (applicable for men)

[audreyh1]

That's Public Service Announcement: on Prostate-Specific Antigen, or PSA testing.

I have a five page summary of my research, I'll spare you all that. I read all I could, but discounted everything that was not from the Cleveland Clinic, Mayo Clinic, Sloan-Kettering, American Cancer Society or National Cancer Institute. What follows is based on my unqualified findings. I was an Engineer, not a Doctor. If a medically trained member wants to correct my understanding, that's welcomed.

Background:
For those not familiar. The PSA test measures the blood level of PSA, a protein that is produced by the prostate gland. The higher a man’s PSA level, the more likely it is that he has prostate cancer. A reading from 0-4 is considered a normal PSA reading (though I learned that's a very generic range that's subject of considerable debate). "PSA velocity" or rate of change from test to test is also (understandably) considered an indicator.

My case:
In Dec 2012, my PSA was 1.8
In Dec 2013, my PSA result was 4.38

My GP referred me to a highly regarded urologist (first available appt 6 weeks later). They took a urine sample and he examined me for 5 minutes. Though I had no other symptoms or history, he scheduled a prostate biopsy, a painful procedure followed by days of blood in urine/stool and risks of infection. Prostate biopsies can come back inconclusive, and a urologist might recommend repeating the procedure as a result. As I had researched PSA testing and prostate cancer while waiting for my appt, I asked the urologist 'biopsy is painful and presumably expensive, would retesting PSA first be a good idea?' With no hesitation he said 'a retest wouldn't change my result,' and he added 'I have no idea what a prostate biopsy costs, but your insurance will pay for it.'

Having read that among about a dozen factors, a DRE (digital rectal exam, sorry) and sexual activity 24-48 before the blood draw for PSA could temporarily elevate the results. Of course I wasn't aware of either when the blood draw was taken, only learned after the fact. My GP did the DRE about 20 minutes before my blood draw.

A PSA test can cost less than $50. Prostate biopsies range from $1,000-$12,000 according to online sources FWIW.

I talked to our health care provider through their "ask a nurse" program, they thought a PSA retest was reasonable.

It's not lost on me what the underlying motivations of the various parties involved may be.

I called my GP to request a PSA retest. The nurse was surprised if not put off at my request, asked a lot of questions and discouraged me, but said she'd talk to the doctor. A week passed and she finally called and said they'd ordered a PSA for me. I went yesterday for the blood draw.

The nurse called me this morning, my PSA yesterday was 1.37. She was very surprised!

So I cancelled the biopsy. The scheduler didn't ask me why...

My intended bottom line here:
There's something to be said for patients taking a respectful role in their health care decisions. My point was not to highlight my case. I am sure some doctors rue the day the internet made so much health care information available, though I am sure others welcome patients who try to educate themselves as long as the patient respects the doctors knowledge and experience.

It's a good thing I'm not easily traumatized, some people might have suffered considerable anxiety being led to believe they might have cancer for almost three months. Unfortunately DW was more worried than I was, she's relieved this morning...

FWIW guys.

Great and important story and thanks for sharing.

This part really bothers me:

With no hesitation he said 'a retest wouldn't change my result,'

First of all that the doctor dismissed a (cheap) retest, and instead insisted on an expensive invasive procedure with some potentially nasty side effects and yet a possibly inconclusive outcome. And clearly he was completely wrong about this.

I really dread dealing with doctors on issues like this, and it seems there are so many of them. It's more than "being informed" - you sometimes end up really having to fight for yourself - and you're the layman. You are forced to second guess your doctor. I can see many patients backing down and just doing "what the doctor ordered". What happened to "first, do no harm"? Something is way screwy.

 

[Alan]

Thanks for sharing Midpack, great info. I had no idea of the advice before having a PSA test, and I have one routinely every year.

From the NHS Guidelines:

Before having the test

If you're having a PSA test, you should not have:
an active urinary infection
ejaculated in the last 48 hours
exercised heavily in the last 48 hours
had a prostate biopsy in the last six weeks
had a digital rectal examination in the last week

 

[Meadbh]

Gentlemen, this is a perfect example of the perils of screening tests. The problem is that the PSA is neither sensitive (it doesn't detect all cancers) nor highly specific (it doesn't reliably exclude normal men if it is under 4).

Sensitivity and specificity of prostat... [Arch Ital Urol Androl. 2006] - PubMed - NCBI

It is, as you have observed, highly error prone if conditions are not optimal. As a result, it must be taken with a grain of salt. The OP's surgeon, while not guilty of manslaughter, does demonstrate arrogance and poor judgment.

The same arguments can be made about mammography. I just received my two year reminder, which I am ignoring.

 

[SJ1_]

.....
My intended bottom line here:
There's something to be said for patients taking a respectful role in their health care decisions...
FWIW guys.

Great post and I agree 100%. thanks

 

[donheff]

Wow. Infuriating. I was never advised about any of the pre-PSA testing issues. Luckily my levels have always been low or I would have gone right along with a biopsy recommendation 5 or 10 years ago. Hopefully, my doctor would have recommended a retest first but, from your experience, some would not. I am stunned that your urologist didn't want to take a much more cautious set of steps. I can't remember the details but the current guidelines recommend not even testing for PSA IIRC.

 

[Midpack]

My interpretation of OP's story is simply another form of a second opinion. With most medical test, it is only an indicator. In this case especially, a blood test can be affected by other variables and even the testing lab. So a follow-up test is more than reasonable. Having a trend over several tests over period of time is probably the best method, not a single test result that could be an anomaly.

Agreed. Though I'd never had a high PSA number or any of the symptoms of prostate cancer. It can be argued that the high result was the anomaly, especially after I learned of two factors that could have temporarily elevated my PSA.

So my primary concern is why did two experienced medical professionals do all they could to discourage my request for a simple retest? The urologist himself told me I had no other symptoms and there's no history in my family either. Spend another $50 vs proceeding directly to a painful $1,000-$12,000 biopsy.

And secondarily, it's no wonder health care costs are so high in the US when providers 'have no idea' what anything costs, and don't care.

The GP and the urologist are considered among the best in our region too, and came highly recommended even by personal friends who are themselves doctors/specialists...

 

[H2ODude]

Very informative post that confirms my skepticism of much of the healthcare industry. I'm also sure that most doctors would prefer NOT to have engineers as patients! It's just in our nature to want explanations for everything! As I've watched my MIL go through many many episodes with the healthcare industry I'm more and more convinced that we need to approach these healthcare decisions with a great deal of skepticism and research, which the latter is made so easy with the internet (which also needs a good deal of skepticism applied). In the case of MIL it's demonstrated that as you age and become perhaps less thoughtful, but more fearful, you are more inclined to just "go along and do what they say." I know in her case, having had half her colon removed 7 years ago (rightfully so) the oncologist was bringing her in annually for a scan, blood work, and consult that paperwork showed cost (yeah, I know, no telling what it really cost) of $12,000. This for an 88 yo woman who barely can walk with a walker, weight 90#. She couldn't withstand any kind of chemo, radiation, or surgery I'm aware of. So why churn all this expense? Fortunately that Dr. left the practice so they cancelled the annual appointment. Which sorta begs the question; if it was necessary why wouldn't this have been turned over to someone else?

Thanks again Midpack for the post, it's a clear demonstration we all need to do our part to question what we are expected to swallow whole no question. Sharing in places like this can be very helpful.

 

[imoldernu]

Current historical review from here:http://https://www.roswellpark.org/cancer/prostate/about/history-psa

One man in six will be diagnosed with prostate cancer during his lifetime, but only one man in 35 will die from it.

My first Prostate Specific Antigen test was in 1990. At the time much much controversy among doctors and medical centers.
No problems, just routine. Received a call from Dr. in a panic... reading 29. Required immediate biopsy. After a manual check, and not finding anything unusual, the surgeion decided that instead of one biopsy... he'd do 7, to be sure. You who have been there know! Early days, larger needles.
Turned out... no cancer... retest of PSA showed 1.7. No apologies for the now obvious misplaced decimal point. Back then, who knew?

As mentioned in other posts... the medical community is upside down once again in analysis and recommendations.

Age can bring on enlarged prostate... more urgency and more nighttime visits. Not neccessarily serious. Depends on the speed of onset of problems.

I ask for test every three years... still around 3.5. Different outlook at ages 90, 80, 70, 60 or 50.

I never give advice... especially on medical stuff, but there's a lot of info out there. Cost to check it our is very low.

 

[Socal Tom]

I previously worked in the medical diagnostic field, so I have a little knowledge in this area, PSA is about 50% predictive of cancer. It's not a great test. There is another test that is much better, but it's not currently approved for screening, only for use after a biopsy, prior to determination if another biopsy should be done. It's the PCA3 test by Gen-Probe. The information is on there website. It's done on a urine sample after a dre, and it is designed to identify aggressive prostate cancer. I think the DR. Of the OP should have offered this test prior to another biopsy.
I didn't read the whole thread, so this may be covered, but it's likely that all men that live long enough will get PC, however. Most PC is slow growing, and will not be the thing that kills us. There is an aggressive form, that can be life threatening, that is the one we should worry about.
Tom

More about pca3
http://www.pca3.org/public/questions

 

[donheff]

I previously worked in the medical diagnostic field, so I have a little knowledge in this area, PSA is about 50% predictive of cancer. It's not a great test. There is another test that is much better, but it's not currently approved for screening, only for use after a biopsy, prior to determination if another biopsy should be done. It's the PCA3 test by Gen-Probe. The information is on there website. It's done on a urine sample after a dre, and it is designed to identify aggressive prostate cancer. I think the DR. Of the OP should have offered this test prior to another biopsy.
I didn't read the whole thread, so this may be covered, but it's likely that all men that live long enough will get PC, however. Most PC is slow growing, and will not be the thing that kills us. There is an aggressive form, that can be life threatening, that is the one we should worry about.
Tom

More about pca3
Questions and Answers | PCA3.org

The Q&As on the site claim the test can (and should?) be performed prior to biopsy because it can add info on the likelihood of cancer. The problem is that most cancers will never progress to death but the only current way to distinguish is with a Gleason evaluation of biopsied tissue (and even that is not definitive). So, the progression is still - PSA/PCA3 can tell you cancer is likely. Then you have to decide whether to just keep an eye on symptoms (DRE and rapidly increasing PSA) or go for the biopsy with its adverse effects and possibility to miss the cancer anyway.

Lousy options all around.

 

[Socal Tom]

True, but the DRE is a better option than 7 needles in my whoohaa. And if canceris there a needle only samples a small region, so it could be missed.
In the longer term I suspect PCA3 will replace biopsy. But it's a new test and it takes up to 10 years to develop the data, since biopsy and PSA are not good prerequisites. So for now it only has that claim
Tom

 

[donheff]

True, but the DRE is a better option than 7 needles in my whoohaa. And if canceris there a needle only samples a small region, so it could be missed.
In the longer term I suspect PCA3 will replace biopsy. But it's a new test and it takes up to 10 years to develop the data, since biopsy and PSA are not good prerequisites. So for now it only has that claim
Tom

Not sure I understand. Even if PCA3 was determined 100% effective at diagnosing cancer I wouldn't be ready to treat. Most cancers don't need treatment so you need biopsies ( maybe multiple) to find out if it is a cancer that needs treatment. Alternatively, you can just watch and see if things blow up (an alternative I would be tempted to take) but you risk being too late for the best treatment.

 

[Socal Tom]

From pca3.org
Recent studies indicate that the PCA3 Score may also differentiate between significant/aggressive and non-significant/indolent cancer (see also PCA3 background information and PCA3 Utility). If cancer is found in the biopsy, the PCA3 Score may give additional information about the significance/aggressiveness of the cancer. This can aid in the decision on treatment, e.g. if active treatment like surgery or radiotherapy is needed or if active surveillance (monitoring potential cancer progression by means of DRE, PSA and/or PCA3) is an alternative. The higher the PCA3 Score, the higher the probability that the cancer is significant/aggressive.

 

[donheff]

From pca3.org
Recent studies indicate that the PCA3 Score may also differentiate between significant/aggressive and non-significant/indolent cancer (see also PCA3 background information and PCA3 Utility). If cancer is found in the biopsy, the PCA3 Score may give additional information about the significance/aggressiveness of the cancer. This can aid in the decision on treatment, e.g. if active treatment like surgery or radiotherapy is needed or if active surveillance (monitoring potential cancer progression by means of DRE, PSA and/or PCA3) is an alternative. The higher the PCA3 Score, the higher the probability that the cancer is significant/aggressive.

I missed that part. If it proves true the test could be a Godsend.

 

[Midpack]

Recent studies indicate that the PCA3 Score may also differentiate between significant/aggressive and non-significant/indolent cancer (see also PCA3 background information and PCA3 Utility). If cancer is found in the biopsy, the PCA3 Score may give additional information about the significance/aggressiveness of the cancer. This can aid in the decision on treatment, e.g. if active treatment like surgery or radiotherapy is needed or if active surveillance (monitoring potential cancer progression by means of DRE, PSA and/or PCA3) is an alternative. The higher the PCA3 Score, the higher the probability that the cancer is significant/aggressive.

I missed that part. If it proves true the test could be a Godsend.

+1, same thought here.

 

[Mulligan]

My interpretation of OP's story is simply another form of a second opinion. With most medical test, it is only an indicator. In this case especially, a blood test can be affected by other variables and even the testing lab. So a follow-up test is more than reasonable. Having a trend over several tests over period of time is probably the best method, not a single test result that could be an anomaly.

Not only will I need to get a second opinion on PSA testing, I think I will also demand a second opinion to determine if I am actually dead or not. This was in the news today.

Embalmers find man alive and kicking in body bag. Poor man in Mississippi ready to be embalmed and he was not ready to go. They think maybe his pacemaker quit and then kicked in again.

Embalmers find man alive and kicking in body bag

 

[powerplay]

Not only will I need to get a second opinion on PSA testing, I think I will also demand a second opinion to determine if I am actually dead or not. This was in the news today.

Embalmers find man alive and kicking in body bag. Poor man in Mississippi ready to be embalmed and he was not ready to go. They think maybe his pacemaker quit and then kicked in again.

Embalmers find man alive and kicking in body bag

OMG imagine the terror that man felt inside the body bag!

 

[lynxville]

My PSA has been elevated for many years. After my last physical PSA came back elevated and they gave me a second blood test, for the life of me I am not sure what it was, but it was not another PSA. Some people just have high numbers. I have had 2 biopsy's, but here is the problem so if PSA is always high, how often do these doctors want biopsy?

In my experience lately doctors are test crazy. Tests tests and more tests. I think I am over tested. By the way if you need a biopsy ask to be knocked out, completely painless, but still the test carries risks.

 

[Midpack]

My PSA has been elevated for many years. After my last physical PSA came back elevated and they gave me a second blood test, for the life of me I am not sure what it was, but it was not another PSA. Some people just have high numbers. I have had 2 biopsy's, but here is the problem so if PSA is always high, how often do these doctors want biopsy?

In my experience lately doctors are test crazy. Tests tests and more tests. I think I am over tested. By the way if you need a biopsy ask to be knocked out, completely painless, but still the test carries risks.

As I understand it, they're simply responding to how they get paid, which has changed over most of our lifetimes.

They're not paid to keep us healthy (as they are at least to some extent in many other developed countries), they're paid for testing, expensive procedures and volume. So they see as many patients as they can and order as many tests and procedures as they can. Like my example in post #1, a doctor spent 5 minutes with me and scheduled a fairly costly procedure, I am fairly certain he'd already decided what he would recommend before he ever saw me.

And malpractice has undoubtedly pushed doctors to test more often than they otherwise might have.

I suspect the health care our military folks receive may be one of the few models left in the US where doctors are paid to keep the troops healthy, not to order tests and procedures.

 

[kcowan]

I had always had a DRE and was OK. Then I got an elevated PSA. Doc said to watch and wait. Next year he died of a massive heart attack (a year younger than me). New doc advises that PSA cannot be done after a DRE so recommends just the PSA. It comes in well within range. So the following year, PSA is stable and DRE shows no concern.

My belief is to remain calm and seek another opinion in any diagnosis. One of my school buddies was an ace in marks and decided to go into meds. I asked him why he did not choose engineering (my choice) and he said he preferred an occupation that was easier.

So I have always viewed my docs as those that chose the easier path!

 

[Chuckanut]

They're not paid to keep us healthy (as they are at least to some extent in many other developed countries), they're paid for testing, expensive procedures and volume. So they see as many patients as they can and order as many tests and procedures as they can.

We should do what the primitive people do. They pay the Witch Doctor say one chicken a month as long as everybody is well. When somebody gets sick the chicken payment stops until the sick person gets well. If somebody dies (except for the very old and very young new bornes), the Witch Doctor gets no chickens for several months!

 

[bjorn2bwild]

We should do what the primitive people do. They pay the Witch Doctor say one chicken a month as long as everybody is well. When somebody gets sick the chicken payment stops until the sick person gets well. If somebody dies (except for the very old and very young new bornes), the Witch Doctor gets no chickens for several months!

Our healthcare system, OTOH is abused because no matter what the cost of the procedure we get off with a modest crowpay.

 

[M Paquette]

Our healthcare system, OTOH is abused because no matter what the cost of the procedure we get off with a modest crowpay.

Written by someone who's obviously not on a Hen Savings Account eligible plan.

 

[franco45]

And there lies the problem. I know an elderly lady who husband was an officer in the military. She pays nothing, not on cent for anything. Her Cardiologist has installed 9 stints in her over the last 10 years. Last week she was feeling a little bad and went into the hospital and same Cardiologist did a cauterization just to "look around" . Cardiologist has a three million dollar home.

 

[kcowan]

ISTR that the US has comparable death rates to other countries even though there are too many invasive surgeries and prescription drugs.