PSA: on PSA Test (for men) - Part 2

[Midpack]

So I had the scare (mostly DW) of a false positive PSA result in 2013. I was forced to learn a lot about it then because my GP, his nurse and the urologist he recommended scared the bejesus out of us - prostate cancer. To make a long story short, I fought them all for over 2 months until they finally agreed to a retest, which turned up low/normal. Shared that here: http://www.early-retirement.org/forums/f38/psa-on-psa-applicable-for-men-70814.html

We moved so I have a new GP, and my annual physical came back with a high PSA again. She referred me to a urologist and insisted I needed a needle biopsy ASAP. I respectfully refused, to her dismay. This GP and her nurse were adamant I needed to see a urologist immediately. When I said I wanted a retest first, they wanted it done ASAP - also bad advice (e.g. a urinary tract infection is a possible cause of elevated PSA, that can take weeks to clear). I’ll spare you all the details, but I waited 4 weeks and got tested at another lab. Got my results back today, 2.4 ng/mL - that’s low/normal for a 40 year old - I’m 65, and PSA usually increases with age. The test is $49, from a blood draw. IMO it’s absurd that a medical professional would fight a patient requesting a retest under the circumstances. IMO they should be recommending a retest in many cases.

• A high PSA reading can be caused by many things that aren’t cancer. Occasionally (approx 15%) of men with prostate cancer have low PSA results. It’s not a highly predictive test for prostate cancer, it’s a possible indicator.
• A needle biopsy is painful, can lead to bleeding and infection, sometimes misses tumors (unless an MRI is done in conjunction), and costs $4-6K. It’s reported 75% of needle biopsies in the past were unnecessary.
• A PSA (re)test is $49...
• Recommendations re: PSA testing and course of action has changed since 2012, but not all doctors know that, including some urologists evidently.

I am NOT a doctor, so I’m NOT telling you to ignore a high PSA result. You should follow up to be sure. But if you’re then told to get a needle biopsy, unless you have other symptoms or family history, I’d wait 4-6 weeks and have another PSA test. Make sure you read up on the causes of elevated PSA, so you can eliminate other potential factors.

I’d encourage anyone confronted with a high PSA to read up and actively participate in what comes next.

There are many good sources of information online, here’s just a few.

https://www.pcf.org/blog/what-are-some-other-causes-of-a-high-psa/

https://www.uchicagomedicine.org/fo.../prostate-cancer-are-psa-blood-tests-reliable

https://www.health.harvard.edu/mens-health/when-is-it-time-to-stop-being-checked-for-prostate-cancer

https://www.cancer.gov/types/prostate/psa-fact-sheet

 

[razztazz]

Gettin' wiggy over PSA tests is quit logical when the motivation has nothing to do with health and everything to do with getting money. This is like the barber telling you you need a haircut, only you can't look in the mirror. They seem to think, actually are convinced, that all patients are stupid and couldn't possibly know anything about their own health or have any information other than what the doctor is telling them. That's been my repeated experience.

 

[audreyh1]

Yeah, but the GP is not making any extra money by referring immediately to a urologist for a needle biopsy are they?

Why do these doctors freak out like this? It goes against current standard of care recommendations.

Midpack - did you get that test done independently, or did you convince your doctor to order another test?

 

[razztazz]

Yeah, but the GP is not making any extra money by referring immediately to a urologist for a needle biopsy are they?

This does not preclude some level or other form of "business relationship."

Why do these doctors freak out like this? It goes against current standard of care recommendations.

I have seen a lot of this sort of creep in to society the past maybe 20 years. Every group is very conscious of they "status." Everybody seems to think they have or need to have some claim to fame, unique feature, something they can hold over other people that they can use to have other infer their unique and exalted power, position, or status. Now, Drs have always had an elevated status in society even when they were killing people with dirty saws, leeches, hallucinogenic seeds and mercury nostrums. They likely see their status (and paychecks) at least metaphysically currently at some risk from affordability issues leading inexorably to "socialsied medicine" and GOOD medical information accessible to more people making them able to question and thereby undermine the doctors power over the patient.

 

[audreyh1]

You are suggesting there is some kind of kickback from the urologist?

 

[CaliKid]

My GP is against PSA tests. He says too many false positives. I took his advice at 50 and skipped the test but opted to take the test at 51.

 

[SecondCor521]

I'm 50. I went through a similar experience at the end of last year. My GP runs my PSA at every annual checkup, even though that's not the recommendation anymore. PSA went from <1 to 5.something from one test to the next. Went through a couple of courses of antibiotics and it dropped to 2.something then <1 again.

My personal, nonprofessional opinion is that at age 50, the chance of me getting PC and it killing me is much much lower than the chance of a needle biopsy either missing the PC or causing some other problem such as infection or other complication. Especially since antibiotics and waiting six weeks seems very cheap, very simple, very painless, and very unlikely to raise my risk of dying from PC to any measurable degree.

IANAD. Consult your own doctors.

...

I'll add that there have been a few times that a doctor and a testing facility have a business relationship. In those cases, they have disclosed it to me preemptively and informed me that I can get the services done at a non-affiliated facility without any problems or adverse action from the referring physician. I don't know if that is the law or just rational business practice.

I have four MDs in my family and have been around medicine my entire life. I've never heard of any doctor getting any sort of kickback for a referral. It may be done on the fringes by some unethical doctors, but I believe it to be rare.

 

[Sunset]

.....

I have four MDs in my family and have been around medicine my entire life. I've never heard of any doctor getting any sort of kickback for a referral. It may be done on the fringes by some unethical doctors, but I believe it to be rare.

Have you heard of Doctors getting kickbacks/payment/gifts from drug companies for prescribing certain drugs instead of generic ones ?

 

[Sunset]

I get a PSA test each year.
One year it spiked high.
My doc recommended getting it tested again, so I did and it was normal.

 

[mountainsoft]

My GP runs my PSA at every annual checkup, even though that's not the recommendation anymore.

I didn't even know what a PSA test was until my last blood work. I didn't know I was being tested for it until I received my test results. At age 55 I got a .81, which is OK I guess.

 

[SecondCor521]

Have you heard of Doctors getting kickbacks/payment/gifts from drug companies for prescribing certain drugs instead of generic ones ?

Nope. My impression is that is not allowed, although again I don't know which law(s) are actually against it.

What has happened though, is drug sales reps (which are sometimes pretty young women) visit doctors offices in person and request appointments to do sales calls. They'll provide trinkets such as sticky notepads and pens with the drug name on it.

They'll also provide free sample packs to the doctors, who in turn generally give them to low income patients for whom the drug is suitable and for which paying or getting the drug would otherwise be a hassle. Or if a patient requests a free sample.

I think there is sometimes pressure from some patients to get the "latest and greatest" drugs, and sometimes, of course, newer drugs are better than older ones. But newer drugs are also usually more expensive to the patients and to the insurance companies, so a compassionate and aware doctor will try to, with the patient, appropriately balance cost vs. medical effectiveness. Usually the priority is medical effectiveness first, then cost second, but it again does depend on the patient.

 

[njhowie]

Never had PSA test, no intention of ever getting it.

 

[bmcgonig]

I had a similar scare last year. Never ever get a biopsy because of high PSA. Get an MRI and one of the biomarker tests like 4k or SelectMdx. And if you do need a biopsy after that make sure you get a trans perineal one, not a trans rectal. My PSA jumped from 4.1 to 5.7 in a year which is worrisome. Upon 1 month retest was 4.5. I opted for MRI and SelectMdx test both of which came back negative. Using the MRI they determined that my prostate volume is about 60, twice average I think. By their rule of thumb anything under PSA of 6 is ok for that volume. ( Unless it jumps a lot in a short period..which as OP stated can be infection etc)

I wrote the following a few months ago here in another thread on how I think someone should proceed if their PSA is abnormal and still abnormal after a 4 week retest. ( Much thanks to urologists on Twitter as well as Peter Attia)


There are a couple of biomarker tests that are very useful in excluding aggressive cancers. One is the 4k test and the other is SelectMDx. They are 95-97% accurate in excluding them. You might still have an indolent cancer but you don't need to worry about them.

The multi parametric MRI can also be very useful in finding or excluding cancers. However it's recommended you go to the most experienced radiographers and radiologists. At best it's 80% accurate I believe. It's more popular in Europe than in USA cos MRI is cheaper in Europe. Also if your MRI is positive it gives the urologist a target for the biopsy. Otherwise they're just throwing darts at your prostate randomly during a biopsy. It's really not very accurate.

The sepsis is almost exclusively the problem in transrectal biopsy. However many urologists now are only doing transperineal biopsies, avoiding the rectal passage entirely therefore practically eliminating infection. They were normally done using general anesthesia, but recently they have come up with a way of doing these under local anaesthesia. Google PrecisionPoint for info. Interesting point is that the percentage of people getting sepsis is actually rising every year from transrectal biopsies because of antibiotic resistance.

I listened to a Peter Attia podcast and he interviewed the urologist that operated on Ben Stiller. His algorithm for troubleshooting high PSA was:

1. 4k test. If negative, go home. (SelectMDX is newer test and might actually be more accurate). If positive then

2. MpMRI. If negative then measure PSA density. That's the prostate volume in cc divided by PSA. If MRI negative and PSA density is less than .15 then go home.

3. If mpMRI positive or PSA density ≥.15 then biopsy.

So if you're being tested and want to avoid biopsy do the 4k or SelectMDx and/or the MRI depending on how thorough you want to be. And definitely find someone that does TP Biopsy if you need one.

One thing I learned is that every urologist is different. Some want to jump to biopsy straight away. Others take a more cautious approach. The problem with testing everyone for PSA was that too many people were going for biopsies and too many people were being treated for minor cancers. I think following the above steps allows you to get the PSA test without too much risk of that. At least that's my approach.

Of course a lot of above might not be covered by insurance. But the 4k and SelectMDx are only about $300 plus a visit to urologist.

 

[bmcgonig]

My GP sent me to a urologist straight away as well. He wanted an immediate retest just to make sure that there was no lab error and once that was confirmed he was done with me as far as PSA was concerned. When I made an appointment with urologist, the urologist said to wait 4 weeks for retest and then come in.

I don't blame a GP for punting a patient to a urologist on a high PSA. The whole test and what to do after is controversial and filled with different opinions that if I were a GP I think I'd want to hand it over to a urologist too. My GP had never heard of the biomarker tests and really had no reason to ever have.

 

[Midpack]

Gettin' wiggy over PSA tests is quit logical when the motivation has nothing to do with health and everything to do with getting money. This is like the barber telling you you need a haircut, only you can't look in the mirror. They seem to think, actually are convinced, that all patients are stupid and couldn't possibly know anything about their own health or have any information other than what the doctor is telling them. That's been my repeated experience.

I’m not quite that cynical, but I will concede the first urologist was very cavalier about doing a needle biopsy, I shared those details in the first thread. I think the GP and the urologist think they have to do something (true), and a needle biopsy will likely determine if there’s a cancer or not (also true, thought an MRI guided biopsy has much better odds).

As for the GP, they can’t be experts on every possible case they face. What she recommended was the norm - before 2012.

But why didn’t they tell me how many others factors can lead to an elevated PSA? Why were they offended that I asked for a $49 retest first instead of a $6K needle biopsy - indeed why don’t they suggest a retest themselves? Why don’t they share the shortcomings of a needle biopsy along with the risks? The cost? The fact that 75% of needle biopsies have been unnecessary?

It’s great what we can find in the internet these days.

And while I encourage patients to educate themselves and participate in their diagnosis where appropriate - I also realize it’s irresponsible to make a doctor field a bunch of stupid questions from an uneducated patient. I’ve found good doctors like it when patients are genuinely interested in understanding what’s going on, and some doctors are offended when a patient has ANY questions.

You’re the patient, some doctors are fallible, educate yourself.

 

[Midpack]

Yeah, but the GP is not making any extra money by referring immediately to a urologist for a needle biopsy are they?

Why do these doctors freak out like this? It goes against current standard of care recommendations.

Midpack - did you get that test done independently, or did you convince your doctor to order another test?

In the first case, my GP scheduled another test.

In this instance, I’m not proud of it but the GP was so adamant I was wrong that I scheduled the retest myself at a Quest Diagnostics. The GP had a nurse drawing blood and testing on site, I wanted to remove that possible influence.

 

[Midpack]

My GP is against PSA tests. He says too many false positives. I took his advice at 50 and skipped the test but opted to take the test at 51.

I don’t know if it was because of me, but my 2013 GP stopped including DRE’s and PSA testing too.

I get a PSA test each year.
One year it spiked high.
My doc recommended getting it tested again, so I did and it was normal.

That’s what should be done IMO along with first telling the patient the other factors that can elevate PSA but I’m 2 for 2 on GP’s and 1 for 1 on urologists that didn’t seem to know that. I’d wait 4-6 weeks before retesting though.

Never had PSA test, no intention of ever getting it.

Prostate cancer is serious so work with your doctor. I would agree to a PSA if only the doctors would do this ^ If you get two high PSA results, certainly above 10 ng/mL, I’d look for a next step.

However, current thinking is no PSA screening at age 70 or thereafter.

 

[target2019]

If a test shows an elevated PSA, get a re-test after a recommended period of waiting. If your re-test is also elevated, go to a Urologist at a research hospital.

 

[Midpack]

If a test shows an elevated PSA, get a re-test after a recommended period of waiting making sure to avoid other factors that can elevate PSA. If your re-test is also elevated, go to a Urologist at a research hospital.

That’s what I’d do with the above added. And that’s what GP’s and urologist should recommend IME.

If you have a DRE before the blood draw that can elevate PSA. If you have sex 24-48 hours before the blood draw it can elevate PSA. There are other avoidable factors.

 

[audreyh1]

In the first case, my GP scheduled another test.

In this instance, I’m not proud of it but the GP was so adamant I was wrong that I scheduled the retest myself at a Quest Diagnostics. The GP had a nurse drawing blood and testing on site, I wanted to remove that possible influence.

I think that’s quite understandable given their attitude and that it could have been their error. But now you have to show them results from another lab?

 

[easysurfer]

IMO, a few factors are in play here.

One, the PSA test is fully accurate. Too many false positives and false negatives. Two, doctors, especially specialists could be very tunneled vision. Three, there may be the fear of liability so ordering the needle test on the patient regardless of possible side effects and impact and inconvenience on patient.

I go to my GP every year for an annual physical. He used to check the old fashioned way (digital, rubber gloves ). For the past few times, he only ordered the PSA test. Each time, the result was normal.

I wonder if the old fashioned way wouldn't been a way for Midpack's GP to do a second check. Of course, that's probably something that maybe a patient may not request as who wants to get tested more that way than needed . Plus, I'm not sure which is more accurate. Old fashioned or PSA.

On the tunnel vision, here's an example. A few years back I brought a relative in to see a neurologist for some tests for a possible condition During the evaluation and testing, to doc and staff seemed to question why a visit was even necessary. After and MRI was concluded that she probably didn't have the condition. But then they wanted to do follow up some other tests anyhow and appointments. Follow up for what? Seemed like the doc wanted to test just to test despite already ruling out what we were evaluating in the first place. Kind of like you go in for pain in the knee, the docs treats you for a pain in the elbow which wasn't hurting in the first place.

 

[Midpack]

I think that’s quite understandable given their attitude and that it could have been their error. But now you have to show them results from another lab?

That doesn’t bother me at all, I scanned and emailed the results yesterday. I assume they’ll see them Monday, and I’ll never hear from them. Who knows, they may surprise me.

My 2013 GP, who we liked a lot BTW, had his nurse acknowledge my normal retest, and they never mentioned it again.

In all fairness, I did not go to the urologist this time. He/she may have recommended a retest for all I know. But based on my first experience where the urologist, GP and nurse told me I was stupid to ask for a retest (“why, the results will be the same”), I chose to get a retest first on my own this time, right or wrong.

And the other thing that REALLY put me off the first urologist. He had very good marks online. He did a quick DRE and didn’t notice anything but told me to schedule a biopsy with his receptionist. I asked him ‘how much does a needle biopsy cost?’ He said ‘I have no idea, but what do you care, your insurance will pay for it!’ I didn’t show it, but I was furious. I wanted to say that’s why US healthcare costs twice as much as other developed countries without better outcomes but I didn’t - he was already angry at me. Dope...

That whole experience changed my views on doctors. Most are great, but the patient should educate themselves and know what’s going on where possible.

 

[braumeister]

As mentioned above, there are various causes of a high PSA reading.

The very first one I had, long ago, was a little over 9 and it scared the you-know-what out of me. Doc sent me to a urologist who guessed it was prostatitis, so he gave me some antibiotics and a few weeks later it was down to a normal level.

 

[bmcgonig]

IMO, a few factors are in play here.

One, the PSA test is fully accurate. Too many false positives and false negatives. Two, doctors, especially specialists could be very tunneled vision. Three, there may be the fear of liability so ordering the needle test on the patient regardless of possible side effects and impact and inconvenience on patient.

I go to my GP every year for an annual physical. He used to check the old fashioned way (digital, rubber gloves ). For the past few times, he only ordered the PSA test. Each time, the result was normal.

I wonder if the old fashioned way wouldn't been a way for Midpack's GP to do a second check. Of course, that's probably something that maybe a patient may not request as who wants to get tested more that way than needed . Plus, I'm not sure which is more accurate. Old fashioned or PSA.

On the tunnel vision, here's an example. A few years back I brought a relative in to see a neurologist for some tests for a possible condition During the evaluation and testing, to doc and staff seemed to question why a visit was even necessary. After and MRI was concluded that she probably didn't have the condition. But then they wanted to do follow up some other tests anyhow and appointments. Follow up for what? Seemed like the doc wanted to test just to test despite already ruling out what we were evaluating in the first place. Kind of like you go in for pain in the knee, the docs treats you for a pain in the elbow which wasn't hurting in the first place.

The test is accurate. It measures the amount of PSA that seeps into your blood from the prostate. The problem is that there's no number that says for sure you have prostate cancer or you don't. You can have cancer with a PSA of 1, and not have it with a PSA of 10. Although as the number increases the chance of you having cancer also increases. However it's the best cheap test available. It just tells you something is not normal.

DRE can find cancer if it's on the outside of the area being tested, but that leaves out that anterior of the prostate and the inside too.

Again some urologists will go straight to biopsy. Others will perform other tests before those. Pick your urologist well.

 

[Car-Guy]

Seems like a PSA thread comes up here several times a year. As I've said several times before, every male on my dad's side of the family has had high (actually very high) PSA's. They all had various related tests and more invasive procedures to evaluate their conditions. None had any cancers and all died of something else in the late 80's/early 90's. However all had problems after those invasive procedures and "some" of those problems lasted the rest of their lives.

I just had my annual checkup and I told my "new" doctor the story above and said I didn't even want my PSA checked again. I already know it's high. He said, I fully understand and don't blame you at all. We moved on.