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

[aja8888]

With a PSA or under 2 at 76 years old, you are extremely unlikely to ever develop prostrate cancer, so you don’t need that test anymore. Why continue with testing when guidelines recommend not to and your risks are so extremely low?

Is "extremely unlikely" 100% sure? SInce my prostate is enlarged a bit, I'll continue to monitor PSA until my female PDP recommends I stop.

I'm one of the lucky ones at my age to have great blood work and take only one med (Tamsulosin) for a urinary issue (which probably cold be fixed with minor surgery). I see no harm in continuing with the PSA test as there could be a "surprise" on a future test.

 

[atmsmshr]

Everyone is different – here is my ‘prostate journey’, fortunately cancer free at this time.
Currently 58 – Been doing the PSA testing since offered at work in my late 40’s. DRE showed enlarged prostate. (Turns out my father has had BPH his adult life). My PSA started high (2.5) and when it reached 4.0 a urologist started me on quarterly testing.

At least two years ago, showed symptoms of prostatitis. A year and a half ago, started periodic 10 day Cipro antibiotics regimen when nerve pain discomfort became constant on my right side. Last September, my PSA went from 4.2 to over 8. Preliminary diagnosis was UTI and another round of antibiotics. Two months later, PSA retest was over 16.

Doc scheduled a prostate MRI with contrast (new gold standard for prostate cancer evaluation), which took 7 weeks from scheduling to results. Lots of anxiety for DW and myself. MRI showed no lesions, but my prostate was more than twice normal size. Since I had symptoms of recurring prostatitis, insisted on a 40 day treatment of Cipro to get rid of the infection. On my own, took zinc and sawgrass to help get the antibiotic to pierce the ‘biofilm’ that may have prevented earlier rounds of antibiotics from completely working.

Near the end of this period, Doc did a rectal prostate biopsy with ultrasonic (which only means more implements to put up the fanny). Almost cancelled because nearly all of my symptoms had cleared and horror stories of biopsy gone bad. A week ago Friday, following novacain injection, twelve guided sample cores 1 cm long were taken. TRUS talk is Friday this week, but fortunately I had signed up with Quest for getting emailed the results. Pathologist results were all normal tissue. No unexpected complications from biopsy. Several months of anxiety is now completely gone.

Next time this comes up, I will just go with MRI and skip the biopsy.
YMMV

 

[bmcgonig]

With a PSA or under 2 at 76 years old, you are extremely unlikely to ever develop prostrate cancer, so you don’t need that test anymore. Why continue with testing when guidelines recommend not to and your risks are so extremely low?

Not to speak for aj's case but personally I will still get the test after 70. Longevity runs in the family (mom is almost 102) and if I found a severe prostate cancer at 70 I would most likely die of it and not die with it. It's not an easy cancer to die of. Quite painful from what I read.

 

[bmcgonig]

Everyone is different – here is my ‘prostate journey’, fortunately cancer free at this time.
Currently 58 – Been doing the PSA testing since offered at work in my late 40’s. DRE showed enlarged prostate. (Turns out my father has had BPH his adult life). My PSA started high (2.5) and when it reached 4.0 a urologist started me on quarterly testing.

At least two years ago, showed symptoms of prostatitis. A year and a half ago, started periodic 10 day Cipro antibiotics regimen when nerve pain discomfort became constant on my right side. Last September, my PSA went from 4.2 to over 8. Preliminary diagnosis was UTI and another round of antibiotics. Two months later, PSA retest was over 16.

Doc scheduled a prostate MRI with contrast (new gold standard for prostate cancer evaluation), which took 7 weeks from scheduling to results. Lots of anxiety for DW and myself. MRI showed no lesions, but my prostate was more than twice normal size. Since I had symptoms of recurring prostatitis, insisted on a 40 day treatment of Cipro to get rid of the infection. On my own, took zinc and sawgrass to help get the antibiotic to pierce the ‘biofilm’ that may have prevented earlier rounds of antibiotics from completely working.

Near the end of this period, Doc did a rectal prostate biopsy with ultrasonic (which only means more implements to put up the fanny). Almost cancelled because nearly all of my symptoms had cleared and horror stories of biopsy gone bad. A week ago Friday, following novacain injection, twelve guided sample cores 1 cm long were taken. TRUS talk is Friday this week, but fortunately I had signed up with Quest for getting emailed the results. Pathologist results were all normal tissue. No unexpected complications from biopsy. Several months of anxiety is now completely gone.

Next time this comes up, I will just go with MRI and skip the biopsy.
YMMV

Congratulations. That's one hell of a worry off your chest.

Next time get the MRI and the 4k test. And if biopsy needed find one that does transperineal with local anaesthetic.

 

[dixonge]

Recently had my first PSA (around age 59) - got it because it came with the other tests I was doing as part of a package. Figured I could use it as a baseline comparison if I ever develop prostate problems. Came up as 1.29.

This article has a good take on it:

"No study has shown that the test saves lives or improves the quality of life. It does not reduce mortality or extend survival in any randomized trial to date, nor when all studies are combined together. Let me say that again: There is no proof that PSA screening extends your life, improves the years you have, or reduces your risk of dying."

The new recommendations for prostate cancer screenings are a bad deal

 

[travelover]

.............. 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!’ ............

My pet peeve. Docs say that we can't expect them to know how much "everything" costs, but surely such a common procedure within their specialty would be reasonable. Ditto with commonly prescribed drugs.

 

[Midpack]

Just wanted to comment on some things that may affect why the doctors behave the way they do:

1. Liability / litigation. As @timbervest described in post #37, being sued is costly both in financial terms and emotional terms to a doctor. Most doctors are trying their best. Being sued could result in financial ruin. A trial can last months and involve lawyers, the patient, the public, and possibly others reviewing with 20/20 hindsight and with plenty of time and effort events that perhaps were more nuanced or time-critical or were more uncertain when they occurred. During the trial, if it gets that far, the doctor has to decrease their workload (thus lost income) in order to participate.

2. Do everything you can to save me/Grandma/Grandpa/my spouse. In the US, we tend to want to do everything possible. We are biased towards action in medical care. Few of us are comfortable with "Go home and do home care; medicine or intervention will not do much for your illness.", "Hospice might be a smarter move.", "Well, there is a longshot treatment, but the chances of it working in your case are, well, a longshot. And there are side effects, huge costs, dashed hopes, and hassle." Most of us want the doctor to just fix it. Most of us don't want to just give up and enjoy the rest of our (unfairly shortened) life. Most of us think that we're the longshot and will beat the odds, however overwhelming. Atul Gawande's "Being Mortal" book covers this aspect well I think.

3. Doctors are very hurried in our current medical system, especially GPs. For a typical patient, the doctor has maybe 15 minutes to do your examination, address your concerns, update your charts, call in your prescriptions, bill your insurance, maybe draw your blood and/or collect a urine sample, check to make sure you're up on your vaccines, and possibly more. Although they're usually smart people who would perhaps enjoy a discussion of the nuances of PSA testing, they are economically penalized for doing so. And for every smart one of us who are knowledgeable about the subject and just have a quick question, there are 10 people who want to argue with the doctor or have a beef about vaccines, or want to have a very long conversation about their diverticulosis to no benefit, or something. So doctors are wary of long conversations based on the odds.

There are a wide variety of doctors out there, and it is good to find ones that you work well with. Most doctors I know will not take it personally at all if you prefer another one for personality reasons or treatment approach reasons.

I try to be knowledgeable and participatory, but I also try to keep my questions precise, relevant, and important.

I don’t doubt any of this, thanks. Patients are partly to blame for US health care costing twice as much as other developed countries. Too many Americans are willfully ignorant re: healthcare and don’t care what it costs as rlong as “it’s covered.”

I also refuse prescriptions whenever doctors permit it - and they usually then confess they over prescribe because most patients get upset if the doctor doesn’t give them a pill...

 

[Car-Guy]

Here’s the boilerplate Quest Diagnostics added to my PSA results FWIW. I can find solid evidence the leading experts changed their recommendations in 2012.


As of 2018, the recommendations for PSA screening have changed. The U.S. Preventive Task Force recommends that men between the ages of 55 and 64 years should determine with their healthcare provider on the need for periodic PSA testing.

Maybe that's why my new doctor agreed with me when I say NO to screening this year. Especially since I'm a number of years beyond the age range mentioned above.

 

[friar1610]

At age 56 I had elevated PSA, was referred to a urologist and had a needle biopsy (only 4 cores but still not pleasant) and was told all was fine.

At age my 58 PSA had gone to 10 and I was referred to another urologist. He put me on an antibiotic for a few weeks (to make sure it wasn't just an infection) and then did a "free PSA" blood test. I forget all the particulars, but this test measures the amount of PSA that hasn't attached itself to some other component of the blood. Its results indicated the probability was that I had PCa. I then had my second needle biopsy (the first with this doc.) This one was 12 cores but because he shot me first with novacaine (or something similar) it wasn't nearly as painful as the first. 7 cores were cancerous with what was described as an "aggressive" cancer.

(In my subsequent research I learned that the earlier 4 core biopsy was listed by the lab as "suspicious" although that urologist did not communicate that to me - he simply said everything was OK.)

I did a lot of research through books, second opinions and discussions with guys who'd been down this road. I went to a few support group meetings where there were guys who had been through what I was going through. Because of the aggressiveness off the cancer, I was advised not to consider watchful waiting and this made sense to me. After considering brachytherapy (radioactive seed implants) and removal of the prostate, I opted for a radical prostatectomy (removal) which I had done at Johns Hopkins in Baltimore. The recovery was unpleasant but tolerable and uneventful. (The damned catheter for 2 weeks was the worst part.)

I will be 75 in May and am in generally very good health for my age. I exercise regularly and have maintained a decent weight as I age. I get PSAs every year and they have been barely detectable (which is the answer you want as this indicates they got all the cancer and none had spread beyond the prostate. There is, of course, no guarantee that there have not been some microscopic cancer cells lurking and that they might manifest themselves someday.) Obviously I don't know what would have happened if I had not gotten the PSAs and subsequently pursued the biopsies and treatment but I do know that I'm alive and kicking at the moment and for that I'm thankful. It will be 16 years since the surgery in October.

I'm not saying my experience dictates that anyone should or should not have PSAs and biopsies when recommended. I think the course I followed paid off in my situation and I relate the above only for any information or help it may give others.

 

[njhowie]

That seems silly to me, unless you are female!
The test can be the first indication of Prostate cancer.

Read my follow-up reply. Not silly at all. If you don't agree, that's fine...for you.

My understanding is that in most cases it is benign and would do no harm if left untreated. The risks of developing it are mitigated by a healthy diet, exercise, and maintaining a healthy body weight.

It's my belief that it's now most prevalent specifically because of some of the points mentioned in this thread - that PSA testing gets pushed so heavily, and there are so many false positives which get acted on. Further, most folks do not eat healthy, exercise regularly, and as a country we are obese - these are known facts. Couple this with the auto-pilot type of response so many physicians and individuals have towards it and it's no surprise that it is now most prevalent.

Personally, I eat healthy, exercise daily, and maintain a good body weight. I am extremely low risk. I've gone to a physician only once in the past 15+ years and that was for a routine physical. Should I develop any of the symptoms of prostate cancer, then I'll have it checked out.

I have no issue with how anyone chooses to address PSA testing or act upon the results in their individual case.

 

[Rambler]

Mid-pack, I’d say wait 4 weeks, make sure you have no nookie, no bike rides, no horse rides, no motorcycle rides, for at least 72hrs, and test again. 2 1/2 years ago, I tested high, at 6.7. I didn’t know the doc would be testing my PSA and had not refrained from a couple of the above. A retest 4 weeks later showed 4.7...still high, but not as high. A needle biopsy followed, confirming cancer. The PSA test saved my life. For whatever reason you’ve tested high on at least a couple of occasions. I’d try to find out why. If I’d have blown it off, I’d probably have stage 4 cancer by now. But with appropriate treatment (DaVinci surgery) I’m still alive, and I don’t have to deal with the typical side effects of PCa treatment. My last follow up a couple weeks ago says I’m still cancer free. I was 55 when diagnosed, 58 now.

 

[braumeister]

I'm not saying my experience dictates that anyone should or should not have PSAs and biopsies when recommended. I think the course I followed paid off in my situation and I relate the above only for any information or help it may give others.

Thanks for sharing that story. I think it's an excellent example of why PSA testing can be a lifesaver in some instances. Of course it's an individual decision, and professional opinions on its value are all over the map, but there are definitely situations where it's useful.

 

[LRDave]

Not to speak for aj's case but personally I will still get the test after 70. Longevity runs in the family (mom is almost 102) and if I found a severe prostate cancer at 70 I would most likely die of it and not die with it. It's not an easy cancer to die of. Quite painful from what I read.

My 95-year-old father has prostate cancer. It metastisized a couple of years ago. It is perhaps in some big bones, his spine and likely in the lungs. Heavy duty hormone treatment slows the growth and spreading considerably. I don't think it will be what ultimately kills him.

 

[donheff]

BMCGONIG posted some good advice. PSA tests should be viewed as a crude alert to potential issues. No one should panic and rush out for a biopsy at the first hint of a high reading. Take some time to educate yourself before proceeding. PCa is rarely an emergency. I had a TURP a couple of years ago to relieve BPH since the surgeon was already in there going after a large bladder stone. The debris from the surgery disclosed a small amount of the Gleason 3+3 - the indolent cancer cells others talked about. In fact may researchers now believe 3+3 is not a true cancer. After tracking PSA for a couple of years my urologist agreed that I no longer need to see him. I will just continue to watch PSA in my annual checkup and return for some of the tests BMCGONIG mentioned if it takes off. The Preventative Services Task Force currently recommends against PSA screening for men over 70. I am now 71 but will continue with the annual test since I do have the indolent PCa and could conceivably have some hidden pockets of more aggressive cells that didn't show up in earlier tests. After several more years I will consult with the docs about whether it is reasonable to stop the screening entirely.

 

[Midpack]

BMCGONIG posted some good advice. PSA tests should be viewed as a crude alert to potential issues. No one should panic and rush out for a biopsy at the first hint of a high reading. Take some time to educate yourself before proceeding. PCa is rarely an emergency. I had a TURP a couple of years ago to relieve BPH since the surgeon was already in there going after a large bladder stone. The debris from the surgery disclosed a small amount of the Gleason 3+3 - the indolent cancer cells others talked about. In fact may researchers now believe 3+3 is not a true cancer. After tracking PSA for a couple of years my urologist agreed that I no longer need to see him. I will just continue to watch PSA in my annual checkup and return for some of the tests BMCGONIG mentioned if it takes off. The Preventative Services Task Force currently recommends against PSA screening for men over 70. I am now 71 but will continue with the annual test since I do have the indolent PCa and could conceivably have some hidden pockets of more aggressive cells that didn't show up in earlier tests. After several more years I will consult with the docs about whether it is reasonable to stop the screening entirely.

Great summary post IMO.

 

[PatrickA5]

Not to speak for aj's case but personally I will still get the test after 70. Longevity runs in the family (mom is almost 102) and if I found a severe prostate cancer at 70 I would most likely die of it and not die with it. It's not an easy cancer to die of. Quite painful from what I read.

Not sure what age is "too old". My dad didn't find out about his prostate cancer until 82. The Urologist basically said that surgery wasn't an option, but radiation could be done, but he'd likely die of something else first. Well, we waited another year and my dad was just convinced he was going to die a horrible prostate cancer death, so he decided to do the radiation. Turns out he lived to 97 and according to his doctor he probably would have died from the prostate cancer sooner.

I have my PSA checked annually (age 61) and will going forward.

 

[grasshopper]

Currently on Active Surveillance for a 1/2 mm tumor 8 years ago. Visit the urologist twice a year for DRE, and PSA test. My PSA is lower than it was at Dx, through weight loss, exercise and a veggie diet. YMMV

 

[Teacher Terry]

Rambler, I am glad that you don’t have any side effects. My husband chose the radiation seeds because they had the least side effects. He still got them all but he would be dead by now without treatment.

 

[TNBigfoot]

IMHO, it is very appropriate to approach a PSA test with caution. Up to 2017, my results were in the 2.5 range however then climbed up to 4.0 which is the trigger point for a biopsy. After talking with urologist, I under went a needle biopsy with 24 cores. Thankfully these came back negative. Since then I’ve bounced between two other urologists. Late last year at yearly exam, test came back at 4.7. Current urologist immediately defaulted to another biopsy. This is when I took the lead to pump the brakes. Held off for 3 months for a retest that came back in same range. So with this, talk of another biopsy ceased for the time being. Medicine is not an exact science and in this case, I’ve become even more cautious.

 

[HI Bill]

So...during an MRI about 7 years ago, they found that I had a tumor on my prostate (this was an incidental find, unrelated to why I was having the MRI), that was pushing into my bladder. Well, that's what was confirmed after a few more tests, including sticking a camera up my urethra.

They recommended a needle biopsy of the prostate. At first, it wasn't too painful. But as they moved to the more sensitive part of the prostate, I couldn't handle it anymore. I told them to stop. I've pretty much decided to never have that test again. My HMO no longer recommends PSA tests, so I'm pretty much gambling, and going unmonitored. My my need for frequent unirination hasn't increased... If anyone has a better idea of how I should be monitoring this, please let me know!

 

[TNBigfoot]

So...during an MRI about 7 years ago, they found that I had a tumor on my prostate (this was an incidental find, unrelated to why I was having the MRI), that was pushing into my bladder. Well, that's what was confirmed after a few more tests, including sticking a camera up my urethra.

They recommended a needle biopsy of the prostate. At first, it wasn't too painful. But as they moved to the more sensitive part of the prostate, I couldn't handle it anymore. I told them to stop. I've pretty much decided to never have that test again. My HMO no longer recommends PSA tests, so I'm pretty much gambling, and going unmonitored. My my need for frequent unirination hasn't increased... If anyone has a better idea of how I should be monitoring this, please let me know!

HNL Bill...I am not knowledgeable enough to give input but go to Healthboards.com and signup for their prostate cancer forum. Lots of very knowledgeable people can speak to their experience.

 

[jollystomper]

BMCGONIG posted some good advice. PSA tests should be viewed as a crude alert to potential issues. No one should panic and rush out for a biopsy at the first hint of a high reading...

This is the approach my GP takes. Twice during my annual physicals over last 15 or so years my PSA has exceeded normal. His recommendation was to not panic, you have no other issues (he does an - ouch - VERY thorough physical exam), lets wait and either check for UTI and retest. Both times the retest PSA was well in the normal range. I'll just keep checking it as part of the physical.

 

[bmcgonig]

So...during an MRI about 7 years ago, they found that I had a tumor on my prostate (this was an incidental find, unrelated to why I was having the MRI), that was pushing into my bladder. Well, that's what was confirmed after a few more tests, including sticking a camera up my urethra.

They recommended a needle biopsy of the prostate. At first, it wasn't too painful. But as they moved to the more sensitive part of the prostate, I couldn't handle it anymore. I told them to stop. I've pretty much decided to never have that test again. My HMO no longer recommends PSA tests, so I'm pretty much gambling, and going unmonitored. My my need for frequent unirination hasn't increased... If anyone has a better idea of how I should be monitoring this, please let me know!

You really need a biopsy. There are two ways of doing a biopsy. Through the rectum and also through the perineum. The latter is normally done with general anesthesia.

I would chase this down in your own area or depending on your insurance get it stateside:

https://www.foxchase.org/clinical-c...rostate-cancer-diagnosis/transperineal-biopsy


https://www.getsurrey.co.uk/news/surrey-news/urology-consultant-prostate-cancer-biopsy-16767751

If you read the attached PDF file on the following link, for the transperineal biopsy using local anaesthetic the pain felt by the patients averaged 2 on a scale of 0..8

https://twitter.com/x/status/1224324711427006465

 

[target2019]

Has anyone been prescribed Finasteride?

 

[Midpack]

IMHO, it is very appropriate to approach a PSA test with caution. Up to 2017, my results were in the 2.5 range however then climbed up to 4.0 which is the trigger point for a biopsy. After talking with urologist, I under went a needle biopsy with 24 cores. Thankfully these came back negative. Since then I’ve bounced between two other urologists. Late last year at yearly exam, test came back at 4.7. Current urologist immediately defaulted to another biopsy. This is when I took the lead to pump the brakes. Held off for 3 months for a retest that came back in same range. So with this, talk of another biopsy ceased for the time being. Medicine is not an exact science and in this case, I’ve become even more cautious.

4.0 ng/mL is a generic limit. It’s well documented that PSA will increases with age, so a generic threshold doesn’t make sense. There are many articles on it, here’s one version, and another interesting set of stats.

And IME your PSA result can be elevated 3X and 4X due to other factors that have nothing to do with prostate cancer.

I am not advocating not monitoring or ignoring PSA results. PSA could point to prostate cancer, but it’s a crude, first step. Absent other indicators - I am suggesting a PSA retest in 4-6 weeks, after making sure you’ve avoided the other factors ** that can elevate PSA - before proceeding with a needle biopsy. And IME some urologists will recommend a biopsy without a retest.

** https://www.medicalnewstoday.com/articles/319551.php#considerations

The AUA also outlined several published “normal” PSA levels by age, based on ethnicity:

Ages 40 to 49: 0 to 2.0 ng/ml for Asian- and African-Americans, and 0 to 2.5 ng/ml for Caucasians
Ages 50 to 59: 0 to 3.0 ng/ml for Asian-Americans, 0 to 4.0 ng/ml for African-Americans, and 0 to 3.5 ng/ml for Caucasians
Ages 60 to 69: 0 to 4.0 ng/ml for Asian-Americans, and 0 to 4.5 ng/ml for African-Americans and Caucasians
Ages 70 to 79: 0 to 5.0 ng/ml for Asian-Americans, 0 to 5.5 ng/ml for African-Americans, and 0 to 6.5 ng/ml for Caucasians

Based on the PCPT and other research, you have:

An 8.8 percent chance of having prostate cancer found on a biopsy if your PSA is 1.0 ng/ml or lower
A 17 percent chance if your PSA is 1.1 to 2.0 ng/ml
A 23.9 percent chance if your PSA is 2.1 to 3.0 ng/ml
A 26.9 percent chance if your PSA is 3.1 to 4.0 ng/ml
A 47 percent chance if your PSA is 4.1 to 10 ng/ml
A 58.3 percent chance if your PSA is 10.1 ng/ml or higher

https://universityhealthnews.com/daily/normal-psa-levels-by-age/