In my opinion, articles like this are dangerous. I delayed having regular PSA tests until my cancer had metastasized, partly because of articles like this one, which seem to come along with some regularity. If speculation about auto-immune diseases being somehow related to early infections is correct, I might have mine because I didn't visit a doctor multiple times in early adulthood when I should have, as a result of articles about the overprescribing of antibiotics.
Why not leave speculation about whether or not to have these tests in the hands of experts rather than give us all the idea that we can be our own? I'm not dead yet, but that approach may have ended up saving my life.
1
There are many questions around PSA testing and there is no one size fits all answer. PSA can be a useful tool, but can be a blunt and inaccurate assay. For me, it indicated true cancer. But, I had a lot more information than an elevated PSA before I treated my cancer.
I am a 57 year old who had a robotic prostatectomy in October. The post-operative pathology showed moderately aggressive cancer in 15% of the central prostate but none in the surrounding tissues. I had cancer, which I knew, and likely am now cancer free, given pathology and subsequent PSAs.
I was first indicated to have cancer via a PSA test at 54. It was slightly elevated; I have a family history. MRI indicated a lesion. A fusion biopsy coupled with molecular analysis indicated a low volume of non-aggressive cancer with a low 10 year risk. I entered an active surveillance protocol involving PSA tests and an additional biopsy. The second biopsy and further molecular biology assays indicated the the cancer was spreading within the prostate and higher 5 year risk.
My doctors and I decided that for an otherwise healthy 57 yr old surgery was warranted. I had it, have not regretted it, and am almost fully recovered in all aspects. If I had been 15 years older, I would likely have not had surgery.
There are no easy answer to these issues. You must talk to doctors you trust and make decisions that suit you.
Please get your annual physicals. They are the most important thing for your health.
8
@Mark
Would you mind sharing who you used for the surgery?
PSA was not supposed to be used in this fashion, according to the man who "invented PSA". I first had my PSA checked as part of standard physical in 2000. It was 2.54. Iwas age 58.
Gradually went up in next few years and I had a HIFU treatment. Which with some hormones was good for 15+ years. This year I had some radiation treatment and PSA latest was 0.35. Lots of new treatments coming out, but don't do anything rash and hurried because of some changes in PSA
1
A PSA screening test for prostate cancer is almost worthless. Unless it's off the charts it doesn't tell you very much. PSA can be high for many reasons like infection, chronic prostatitis, recent ejaculation or many others. The problem is that it's difficult to know why it might be elevated. The only way to get a better idea is a biopsy that is taken via the rectum. That opens the door to infection so you better have a good reason to do one. It's not something that you want to do repeatedly. Most biopsies are negative which means that you went through a painful procedure that could have killed you.
I know this because 30 years ago, I went to the doctor because of what I suspected to be a pelvic infection. The doctors were not receptive to that so they blew me off until one day they decided to do a PSA test. The level was elevated which sent them in the "we have a number" frenzy, speculating that I had a 65% chance of having cancer.
At first, I was shocked but then I did my research and found that a PSA is mostly good for knowing if you have a prostate gland and that's about it. They wanted to do the rectal biopsy and I said no. They even sent me a certified letter to let them off the hook, so convinced they were that I probably had cancer. Then on a subsequent visit they finally agreed to take my urine. Guess what? I had a raging infection and my prostate was inflamed. A course of antibiotics and I was back to normal. Thirty years later I'm still here.
14
In the UK , PSA is not offered as a national screening programme. The low specificity excludes the test as a screening tool.
MRI ,with a focus on the prostate gland , using the mpMRI technique is favoured. To set up a screening programme is expensive but may be the way forward. It`s claimed a negative scan in middle age means further examinations in later life are not required. A one off screen is enough. The benefits of early detection and grading of prostate cancer to be evaluated .
NHS England has been running trials since 2018. If it`s cost effective , a screening programme may be introduced. Fingers crossed.
2
At 65 on my annual had a PSA of 7.2. I have never had any problems with urination. The first urologist pretty well raped me trying to be a hero to find a tumor that was not. I did another PSA 10 days that showed I was up to 7.8. On my own dime a week later I had a Lab Corp test that showed I was down to 7.6. My father was diagnosed having prostrate cancer in his early 70s. He never did anything and died at 80 of pneumonia. He also had no continence problems.
They wanted to do a proctectomy or chemo on me. In the last years I have done incredible physical things which I don't believe I would have been able to do if I had gone thru what my urologists wanted me to do. I have had a mri, biopsy. The bp came back with 3 cores in the very low 3s and one a 4.2.
I have no grand kids an one estranged son. If I had close family ties or grand children there would be no question I would have had to go the recommended route. We have two institutions in our country that are corrupted. One is our health system, the other is our military complex.
If I bite the bullet I would like to leave my estate to a non corrupted cancer institute that specializes in prostrate cancer. I would gladly prefer a pay as you go health system to the one we have now. My doctor would like to get rid of me since I would rather get my flu and pneumonia shots at the pharmacy for one fourth the price he would charge. Iam close to seventy going strong.
6
this lady seems an odd person to be giving such questionable advice. why would the NY Times agree to print this? Jane Brody should stick to squeezing oranges.
2
The argument to not test is spurious, based on population-level statistics, not individual probabilities. It looks reasonable till you are the person at risk. In general men don’t get preventive screenings for anything, even an annual physical. This is an easy test to do along with an annual physical looking for more dangerous stuff like blood pressure and heart, far less costly and cumbersome than a mammogram.
Finally got my healthy youthful surfer 60-something husband to get an annual physical with PSA and found a somewhat elevated PSA, which was monitored each year (trend line), then took a sudden jump. Bingo! Biopsy with result that cancer seemed contained but was located on a perimeter that could spread, however slowly. Then DaVinci by expert surgeon and a safer future.
This ageist notion that you don’t need one after age 50 or 60 or 70 is ridiculous as well. Insurers are now advocating a biennial mammogram after age 50 due to population statistics. Per my OBGYN, you put a pool os 20-somethings with a pool of 60-somethings and you get a watered-down probability. Likelihood increases as you grow older, so more important to screen. Same applies to men.
1
@Patricia It's quite one thing to look back in your time machine binoculars and recommend something that turned out to work for you. It doesn't work for most people that have an elevated PSA. Most go through a lot of pain and or expense only to find that there is nothing there. If there is a biopsy, the final tier of the detection process, there is a good chance of infection. Most prostate biopsies are either inconclusive or negative.
I am not sure what the best answer might be but I was told that I probably had prostate cancer when I was 45 based on an elevated PSA. At the time, the only thing available before prostatectomy was the biopsy. I chose to ignore it. I'm seventy now so should I recommend that everyone not take the test?
3
THE PSA TEST IS ABOUT INFORMATION NOT TREATMENT!
Don't blame the test for overtreatment, blame the medical community who are too eager to treat, and poor communication between nervous patients and overly aggressive practitoners, perhaps driven by motives other than the patients' well-being.
The more people we test, the more lives we save. Rather than looking at it in epidemiological terms, consider the recent rise in prostate-specific deaths that correlates well with the USPSTF recommendations in 2012 and 2016 to reduce PSA testing.
And consier the rise in metastatic diagnoses in younger men. We (https://ancan.org) now run a specific virtual group for U-60 men with advanced PCa.
4
This really bothers me. My husband was a healthy, active man in his 60s when he was diagnosed with metastatic prostate cancer in 2014. He died in July of 2018. He had had a biopsy two years before, almost to the day, which came out negative. No prostate symptoms, just severe pain in his thigh, which we assumed was a pinched nerve or sciatica. He had regular screenings, and his PSA was always slightly elevated, but they did multiple biopsies and found nothing wrong till it was too late. When he was diagnosed, people told him all the time that something else would kill him before the PCa. Clearly not the case. I agree one shouldn't be alarmist, but as mentioned below, all prostate cancer is not the same. Hopefully with further research, as the article suggests, ties of aggressive disease to genetic information will help separate men who need more aggressive monitoring from those who do not.
18
Not all men are created prostate cancer equal in America.
Black African American men are separate and unequal in prostate cancer occurence and outcome to white European American men.
Why?
Color aka race, ethnicity and/or national origin?
Economics, education, history and/or politics?
Age and/ or genetics?
Any and/ or all of the above?
2
10 years ago I agonized whether or not to undergo radiation or surgery to treat my prostate gland. I had problems with enlarged prostate and was monitored routinely by digital exam. One day the doctor recommended a biopsy due to the way the gland felt and what the PSA detected. The biopsy revealed cancer but there was never a discussion on watchful waiting or active surveillance. I opted for a daVinci procedure to remove the gland. I wanted it out and examined. It had not spread beyond the allowable perimeters. After a few months of healing I was attaining erections and no incontinence to speak of other than an occasional leak upon exertion. I enjoy an active sex life as any 70 year old man can. I don't have incontinence. I owe these results to a skilled surgeon. I get a PSA test every year and will continue to do so. I owe my life to monitoring my progress over the years.
13
Get the test! It saved my husband’s life since his doctor caught the cancer early!
10
Having PSA tests saved my life. I’m a fan.
11
This article is patchy. Some good information but generally bad level D information. As a urologist who treats prostate cancer, I know the anxiety that the C word can have on patients when I tell them they have it but we can just watch it. I also see the bewildered look when we diagnose an aggressive variety in a guy with a PSA under 4. Not uncommon.
9
There are also concerning reasons that tumor markers and other lab tests should be available, without MD/practitioner orders, via over-the-counter and at diagnostic facilities, anonymously if preferred (with a random generated code perhaps). These type labs should be easily accessible for all tests, and standard and common practice, not an exception. People deserve and should have far more autonomy, and the medical profession less power, at least in these regards. Most clinicians are wonderful, but horror stories are ever more prevalent, often regarding money, but other factors as well. My own labs have been deliberately altered as retaliation for whistleblower complaints. The ramifications of such actions can be as serious as deliberately masking disease diagnosis or progression.
See my site (ourconstitution.info) and linked book at my Home page (no cost), "Absent Due Process - Audacity of Evil - Students Against Extrajudicial Killings: Rise of the Medical-Military Industrial - An Introduction -" - detailing my concerns as a former grad student as well as someone who worked for 12 years at a powerful university with a hospital and med school. Demand increased protections for patients, students, and all of us.
so many nyt articles about delaying psa screening. I believed them all.
today, I went for my first radiation for this cancer. I guess I was stupid.
8
I am so sorry to hear about this. I hope you will be cured after your treatment. Do see my concerns in my letter above. The NYT has been a trusted source for information, but if one is not in the science field, or health, this topic, to many people, is very foreign. We do need to be focused on prevention in the US, and tumor markers and other routine labs, and probably some scans, are important, non-invasive indicators for everyone, that should be encouraged.
The health-care system is a mess, and a vast subject, but a few more alarming issues...
There are concerns that entities will balk at the notion of comprehensive preventive care due to the fact that certain (treatment) industries will make much less money. Some go so far as to posit that "bad" habits help "fund" certain medical/surgical specialties (smoking, alcohol, sugar, etc.).
Certainly not out of the realm of possibility in our society, unfortunately... I think these industries (and/or users) should pay the cost to society of these substances. A pack of cigarettes might be $1000 or more considering likely future costs; we all have desires we cannot afford. We should NOT ALL continue to pay for these "leisure/recreational" habits and their related future illnesses and medical costs. You can bet these industries would balk at this, but it would certainly free up a lot of money for the sufficient outreach, knowledge, and preventive care that we all should have, but many now do not know about and/or cannot afford.
2
Good article and discussion. My opinion, as a reasonably healthy 66 year with PSA 3 in 2016, 6 in 2019, biopsy in 2019, Gleason 4+4 in one of 15 cores and 3+3 in 9 cores is that routine PSA testing for men over 50 is wise. I'm not a candidate for watchful waiting or brachytherapy. Planning to have surgery shortly. Sloan-Kettering has some useful prediction tools designed to help patients and their physicians understand the nature of their prostate cancer, assess risk based on specific characteristics of a patient and his disease, and predict the likely outcomes of treatment. https://www.mskcc.org/nomograms/prostate.
4
My 89-year old father’s internist chose to follow the guidelines of not screening PSA levels after ages 70 and thus did not detect my fathers prostate cancer—the aggressive variety, usually found in younger men—four years ago, which nearly killed him. Thankfully, my dad responded well to radiation and immunotherapy and has managed to overcome his stage 4 prostate cancer. It is a travesty that it was not detected sooner. (At age 70, my father was in very good health, and should have been in the healthy-longevity category of men who continued to be screened regularly.) As the result of the cancer moving into his bones, my father required a hip replacement and now uses a walker to get around safely; he cannot risk a fall with his cancer-brittled bones. He can no longer play golf, but thankfully remains healthy, albeit a ghost of his former robust self.
6
The comments from informed readers make this article even more valuable. Thank you. For me it will boil down to a judgement call after as much information as possible is acquired in a reasonably short period of time.
6
We have the NHS here as you will be aware. However, I went for a paid-for health check up in 2008 at age 56. Amongst the usual tests performed, I got a PSA. The results game back at 4 and I was advised to seek advice from my GP. They sent me for another PSA test and ultimately for a biopsy. This came back with a negative result but the consultant did advise that I had an enlarged prostate. Apparently this is not all that unusual though it does present a different set of problems. I was advised to continue having PSA tests and over the years the results ranged from 9 to 30. I have also had another biopsy. I am still here 12 years later and still having PSA tests - the last one was 11. Let's hope better techniques do come along that are more accurate and less intrusive as a the biopsy. Anyway, perhaps there should be a formula that sets a 'normal' PSA range based on the size of the prostate rather than the global threshold being around 4 for triggering further action, Or, does size not matter?
4
@Ken C
That test is done.
Measure volume of prostate with MRI or ultrasound and calculate quantity of PSA per unit volume (called PSA density).
The test doesn't really seem to be very helpful because the problem is obviously more complicated than just PSA.
2
PSA tests are not perfect but they can provide potentially life-saving information. After years of PSA tests, my primary care doctor saw a rapid rise in my PSA. I had no other symptoms (no suspicious digital rectal exams, no urinary problems, etc). He referred me to a urologist who, because of the lack of any other symptoms, did not go directly to a biopsy. A 4K blood test showed I was at elevated risk for aggressive cancer and we agreed a biopsy was necessary. It (along with an MRI, ultrasound and other testing) confirmed I had an aggressive enough cancer that treatment, not active surveillance, was called for. The suspicious PSA result is the reason my aggressive cancer was detected and treated early.
Men need to understand that a suspicious PSA test does not have to lead directly to a biopsy - additional, non-invasve testing can be done first. If such additional testing suggests the PSA result is likely a false positive, then men (and their doctors) can choose to forego biopsy. Men also should understand that a finding of cancer in the biopsy does not necessarily indicate invasive treatment. Active surveillance of less aggressive cancer is now common. Active surveillance does not mean doing nothing - it means periodic testing such as PSA tests, MRIs, etc.
The very real problem of over (and under) treatment for prostate cancer is not caused by PSA screening. What men and their doctors do with the test results is what matters.
22
I find personal narratives interesting, sometimes even compelling, but of little scientific value. Let's say a test produces a high percentage of what we can loosely call false positives (no abnormality, or cancer that will go nowhere, or benign prostatic hypertrophy). By definition, it will be correlated to a smaller but real percentage of escapes from metastasis.
Persons for whom the test "worked" will understandably testify to its benefits. They will not identify with the far larger number of persons for whom the PSA misleads into unnecessary trauma. Like Brody, they'll tend to shrug off or ignore what PSA's lead to: "Watchful Waiting." That's a euphemism for a needle biopsy.
For those who haven't enjoyed a biopsy, imagine 16 or more large gauge needles rammed through the wall of your rectum into a golf-ball sized organ richly supplied with nerves and blood supply. With the best of outcomes, you'll urinate blood for days. Less happy outcomes that occur at non-trivial rates include infection, and permanent damage to the nerves that permit sensation and arousal downstream.
Got that image and the risks? Now repeat "watching," every year or two. Until there's more scar left than prostate.
Such mutilation is shrugged off by urologists as a mere irritant, a "pinch" worth a tradeoff with cancer. Put that way, certainly. Yet one wonders why apologists don't face the number of unnecessary biopsies triggered by a scientifically questionable PSA.
4
@SMB What you describe is usually referred to as "active surveillance" more commonly used to describe one of the options after a biopsy actually detects cancer, or possibly if something suspicious is found that the pathologist is not quite ready to call cancer. (I had that once; ignored it.) "Watchful waiting" is more likely to be the term used to describe an option of not doing a biopsy after a high PSA result and consists of measures like more frequent PSA and DRE tests, far less drastic than a biopsy. (Perhaps these terms are sometimes used interchangeably.)
"With the best of outcomes, you'll urinate blood for days" seems wildly exaggerated. This is only anecdotal evidence, but in my four biopsies I had at most a small amount of blood in my urine for only the first urination after the biopsy. And for what it is worth I had nothing worse than a certain loss of dignity in those procedures.
9
Yours is anecdotal...I did not have a drop of blood..more anecdotal thoughts
2
I’ll agree the biopsy is painful for a few hours afterwards. In my case it resulted in a Gleason score of 7. I then had robotic surgery removing my prostate and which unfortunately showed that the cancer had spread a bit to my bladder. So far so good but if I had the PSA earlier the cancer could have been caught before spreading. My previous GP didn’t believe in the test so when I happened to switch doctors and had a PSA test return with a value over 9 that was an unpleasant surprise.
My advice is to get that PSA.
Paternal grandfather and both of his brothers died of prostate cancer. Two second cousins tested, discovered to have it, and successfully treated. If it has occurred in your family, get tested. Ignore the comments of those who have never had it in their families, and I'd suggest that if men don't need testing for prostate cancer, women don't need testing for breast cancer or uterine cancer, while youngsters don't need to be vaccinated for polio, MMR, and other potentially fatal childhood diseases. What is medicine, but a tool for overpopulating a shrinking planet? On the other hand, intelligent species use tools.
10
A new paradigm that does not rely on PSA is on the horizon. Earlier this month in San Francisco at ASCO-GU, the largest scientific event for the urologic oncology community, a study of 1,436 patients demonstrated an incredibly accurate and non-invasive new liquid-biopsy platform technology that – using a single urine test (and nothing else.. no PSA, no DRE, no family history – a complete standalone test!) – can detect the presence of prostate cancer in patients and then, among those diagnosed with the disease, accurately distinguish between those harboring aggressive cancer that requires immediate treatment and those with low-grade prostate cancer that needs only to be monitored. The study, lead-authored by Dr. Lawrence Klotz who is Chair of Prostate Cancer Research at Sunnybrook Health Sciences Centre in Canada, established that the test for detecting cancer in patients had a sensitivity of 94% and a specificity of 92% and that analysis to classify patients into low-grade (GG1) and higher-grade (GG2-5) disease categories had a sensitivity of 93% and a specificity of 90%. This level of accuracy from a non-invasive urine test can dramatically reduce the need for invasive, often unnecessary procedures such as core-needle biopsies and its related morbidities. The technology was developed by miR Scientific, a bioscience company from Albany, NY. Hopefully Ms. Brody will address this in the next article.
18
@Tal would like to read more about this.
The problem still seems to be how to match the appropriate treatment to the needs and concerns of the patient.
When and where is this new liquid biopsy alternative to invasive biopsy available? Would much prefer my husband do this!
4
For many years, I have been puzzling over the logic of "aggregate benefit" of PSA testing (which seems small but might be an over-cooked number) versus "personal benefit" (which can be life-saving). Help me!
Funny to see no mention of fPSA scores (which should always be done, duh) and the quite better DNA detection tests like PCA2 (if I recall correctly).
In practice, assuming as every writer here seems to, that ignorance is dumb, the diagnosis of prostate cancer is quite reliable. The single hitch is the risk of infection (and the general distastefulness) of a biopsy. The smart move is to get an MRI before the biopsy to ensure there is something bad present and to guide the locations of the sampling needles.
9
For many years, I have been puzzling over the logic of "aggregate benefit" of PSA testing (which seems small but might be an over-cooked number) versus "personal benefit" (which can be life-saving). Help me!
Funny to see no mention of fPSA scores (which should always be done, duh) and the quite better DNA detection tests like PCA2 (if I recall correctly).
In practice, assuming as every writer here seems to, that ignorance is dumb, the diagnosis of prostate cancer is quite reliable. The single hitch is the risk of infection (and the general distastefulness) of a biopsy. The smart move is to get an MRI before the biopsy to ensure there is something bad present and to guide the locations of the sampling needles.
3
I have a standard annual checkup with my family physician whose background is internal medicine, which includes a standard blood workup and PSA test. The PSA test is inexpensive and simple. My PSA (ng/mL) had trended upward over five years: 2014 - 1.8; 2015 - 2.4; 2016 - 3.1; 2018 - 5.4 (4.2 repeat, different lab). A level of 4.0 ng/mL is considered a "limit" to begin looking more deeply. The steadily increasing values is probably more important since it indicates a pattern. A urologist performed a needle biopsy returned: 2 zones Gleason score of 7, 3+4 in a) Left lateral apex (70% of length) and b) left base (5% of length); 1 zone Gleason score 3+3 in left apex. Images of biopsied wsamples clearly showed areas with a moderate of differentiation. He recommended focused radiation treatment which would require >35-40 weeks of weekly visits. I chose to have radical robotic surgery completed in September 2018. No regrets. There is little cost or downside in periodic monitoring PSA levels and then looking more closely when/if the test result a) reaches a range to raise concerns and importantly has significant trending upward.
9
"... approximately one man in six who were screened was falsely identified as possibly having prostate cancer..."
What does this mean? Do not ignore that word "possibly". Positive PSA result says it is worth paying attention to the prostate not that you have cancer.
"... and two-thirds of positive results in the first round of screening were false positives"
Is a blood test for high cholesterol a false positive if the patient doesn't eventually have stroke? PSA test does not determine if you have cancer, just whether you need to pay attention.
Urologists are more nuanced in interpreting PSA results than this article implies.
6
I am a 70 year old Male with am enlarged prostate. I have had an MRI scan and they found a small cancerous tumour about 3mm. I have been assured from quite a few medical experts that I would die with the tumour rather than from it. I hope this reassures some of you.
Bryan Temby from the uk
5
@Bryan Temby Bryan, I don't know what your general health in other respects, but, if all else is good, I'm wondering if you'd really be OK with a dying a slow death in your 80s from prostate cancer that eventually metastasized throughout your bones and body? Those reassuring doctors likely won't be around, and won't be able to do much for you if they are.
I watched my otherwise healthy father die that way after his absolute faith in his doctors to do the right thing by him turned out to be unfounded, years down the road.
It was senseless, sad, and ugly.
7
There are also concerning reasons that tumor markers and other lab tests should be available, without MD/practitioner orders, via over-the-counter and at diagnostic facilities, anonymously if preferred (with a random generated code perhaps). People deserve and should have far more autonomy, and the medical profession less power, at least in these regards. Most clinicians are wonderful, but horror stories are ever more prevalent, often regarding money, but other factors as well. My own labs have been deliberately altered as retaliation for whistleblower complaints. The ramifications of such actions can be as serious as deliberately masking disease diagnosis or progression.
See my site and linked book (no cost) detailing my concerns as someone who worked for 12 years at a powerful university with a hospital and med school. Demand increased protections for patients, students, and all of us.
5
@ourconstitution.info
What website, what book, and are you aware that it's already possible to obtain virtually any lab testing without a doctor's order?
@Paul B
Thank you Paul. Sorry, I should have clarified that the website I am referring to is ourconstitution.info. I know about some of these labs that will test without an MD order -- not sure how many allow anonymity and/or tumor marker testing (and other labs), and it seems that most people don't know about them.
These type labs should be easily accessible for all tests, and a standard and common availability, not an exception. My book is, "Absent Due Process - Audacity of Evil - Students Against Extrajudicial Killings: Rise of the Medical-Military Industrial - An Introduction -" (link at my Home page).
The PSA test is a painless and inexpensive blood test usually done in concert with other routine blood tests. The test value correlates with the enlargement of the prostate. It does not test directly for cancer. Perhaps more significant than the resulting value is the progression of those values over time. Most arguments for declining screening are stochastic arguments designed to turn one into a betting man. One could apply the same argument to all screening tests to encourage everyone to avoid annual physicals. The logical decision point what to do should not be prior to the PSA screening but after afterwards. Then you can can decide if you want to roll the dice or not.
It should also be noted that the USPTO service is made up is 16 well qualified healthcare professionals. However, not one of them is a urologist or oncologist.
10
One of the top cancer docs in the country once told me “if you live long enough, you will definitely get prostate cancer. But it’s not certain that it will be the thing that kills you.” In the age of tests for everything it’s important to understand the weight with which one should carry a given result. PSA tests exist within a fairly gray statistical zone. Do your homework and, above all else, talk to a doctor you trust about the results.
7
Tired of minimizing prostate cancer.
My dad had it. Was given hormone treatments in his 70’s : 80’s. He died after bouts of colon cancer and stomach cancer at age 97.
Very important not to minimize regular check ups guys.
11
Since I turned 40 I have been diligent in having an annual physical, which always included blood work. My PSA always ranged within the safe-zone between 2-4. Until my physical in 2018 (I was 62) my PSA measured above 20. Subsequent testing showed an extremely elevated PSA far above my historical baseline. A biopsy showed cancer in the left node of my prostate. My oncologist described the three treatment choices: active monitoring (he said I was too young for this, as it is mostly prescribed for much older men); radiation (which does not support eventual removal of the prostate and saving of the nerves); and removal (which in my case provided for saving of my nerves). After surgery and subsequent bloodwork I am, so far cancer-free. I know of many men who did not have their annual physical and bloodwork done and succumbed to cancer. So many lives cut short due to a missed opportunity to measure, monitor, and maintain one’s health. Until science comes up with more proven and better measuring/monitoring technologies, the current methods of PSA as a component of an annual physical remains the best way to prolong one’s life cancer-free.
23
@Kevin Callahan
Amen Kevin.
Additionally, the advances they're making in detection, location, and treatment seem to be occurring monthly, not yearly.
And a heads up to fellow Vietnam Vets. The VA has determined that PC for us maybe particularly aggressive because of exposure to Agent Orange.
I was there 71-72 after they'd ended its use, but was an advisor drinking well water where it'd been applied.
Point -VA doesn't cover things wo having strong epidemiological evidence for it.
So no matter when you were there or doing whatever, get checked out and keep doing so.
That's an order GI.
7
After fourteen months of my PSA values fluctuating up and down; with the last three counts trending upward, I reluctantly agreed to a prostrate biopsy. My wife (a nurse practitioner), my GP and urologist all wanted me to go forward. That said, I had no symptoms. My urinating was fine, I was having erections/ejaculating and my DRE’s were unremarkable. Within 24 hours of my biopsy, I was in the ICU with 103.5 temperature and full blown sepsis. Luckily, my sepsis (systemic blood poisoning) was diagnosed within 20 minutes, which likely saved my life. FYI: 50% of sepsis patients, don’t leave the hospital alive. Pay attention to any symptoms after a prostrate biopsy. My “Ex-urologist” had advised me not to take the 500 mg of Levaquin (antibiotic) prior to the procedure because I was finishing a regiment of Doxycycline for an ongoing sinus infection. (The biopsy procedure should have been postponed) I was released from ICU four days later and prescribed Cipro for ten days. I had a delayed allergic reaction. The last day on Cipro I urinated pure blood. (That will freak anyone out; trust me) My liver was shutting down from the Cipro. There’s more...Same ER, same diagnosis; SEPSIS, again! Another four days in the ICU. I survived sepsis twice, within a fourteen day period. We all have to come to our own conclusions and decisions regarding our health. Please, do not rush into any potentially life altering procedures without doing your research! BTW: Know any good malpractice attorneys?
18
@Paul
Look into studies where the prostate biopsy is done using a transperineal approach instead of a transrectal approach. Accessing the prostate by punching hollow needles through the colon just doesn't sound like a good idea at all.
1
@Mike B
Agreed. Thanks.
As a 69-year-old man, I find this article and the attitude it reflects horribly partronizing. I’m quite capable of deciding how to respond to a positive PSA test and honestly can’t believe that the authorities think I would be better off with less medical information rather than more.
15
I am exactly your age and agree with what you say here. Let me decide as a mature adult whether or not to get this test.
3
The article leave out some possibly pertinent information. With an elevated PSA, and cancer is found to be present, are the cancer cells aggressive? That can be diagnosed. Also, what is that person's Gleason Score, a much used measurement of urologists to indicate how aggressive the cancer is. Please do a little more research when writing about such an important topic.
10
Why do men in Okinawa (a 5 Blue Zone) have the lowest prostate cancer? It' why I don't eat red meat.
1
As the various perspectives in the comments reflect, decision making involving anything connected to cancer, the disease we fear more than any other, is particularly challenging. Though we try to make such decisions based purely on data and medical evidence alone, we see that evidence through the lenses of how we FEEL. this is entirely valid and intrinsic to human cognition, but it can lead to choices that end up feeling right but doing more harm. Just being aware of that is helpful. There is much more on this, re: prostate cancer, in an opinion piece I wrote for the NYT a few years back...for what it's worth. "Cancer on the Brain"
https://opinionator.blogs.nytimes.com/2012/06/02/cancer-on-the-brain/
1
I don't understand why people are so anxious to make their own decisions on complex medical issues, where the clinical trials show such poor results. "Screening does not reduce mortality" seems pretty simple to me.
https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening1
2
@Gordon Prince
It's because there's a 1 in 8 chance of getting prostate cancer for any given male over their lifetime. And we're not talking about a $10,000 MRI to detect potential issues. It's $30-40 (see my answer below.)
The logical thing to do with these sorts of numbers is just monitor the PSA numbers, starting at some reasonable point, and then everyone can have a grown-up conversation about whether to take any further action.
What I don't understand is the notion (which seems to be the dominant trend in the medical community) that we shouldn't collect data at all. The body is far too complex, and there's too much variation amongst individuals, to assume that a one-size-fits-all approach works in testing and how the human body responds to disease.
8
@Gordon Prince
Prostate cancer is deadly. Men in their 40s with young families are dying regularly of this brutal disease. The USPTF recommendation against PSA testing is killing men, and the death toll will only increase. In fact it already is, a simple search of youtube for recent urology conferences on the topic will show how horribly misguided the current screening recommendations are.
3
Keep in mind that hospitals have made huge investments in robotic surgery, MRI equipment etc. Remember that surgeons make money doing surgery. Remember that doctors get bonuses for being more "productive". Don't rush into major surgery. Make sure it is the right treatment for you, not for your hospital's and doctor's bank accounts.
5
That’s a viewpoint and attitude that may surely provide you with a reduced lifespan. What is wrong with trusting The Science?
6
Disagree with the premise. I had a friend who did the watchful waiting trick for his prostate cancer. He died of prostate cancer. I had an incrreasing PSA, followed with scan, then surgery. I get to die of something else than prostaae cancer.
Jane, you don't have a prostate, so I suspect your insight may not pertain to say 100% confidence level. . Maybe 50%.
Cordially
ddepperman
14
This theory should be debunked once and for all. There is no advantage to not knowing the results of a test than can potentially save your life. Using the argument that the risk of being treated unnecessarily when you have very slow growing cancer outweighs the risk of knowing you have advanced disease is utterly ridiculous. A PSA test is nothing more than an indication to check further. It's not perfect but it's the best simple and relatively inexpensive test we have at the current time.
17
I agree with you. Give me the test and give me the ability to decide with my doctor what to do about elevated PSA. Telling a mature adult you don’t need to know what might be wrong with you, especially when there are therapies in case something is wrong, is positively Orwellian and condescending.
5
@Mark Siegel Couldn't agree with you guys more. Unfortunately, and maybe more unbelievably, there are men who want to take absolutely no responsibility for their own health, and are quite comfortable leaving decisions about having a PSA test, or any kind of subsequent treatments related to urological problems, completely up to their doctor. My father was such a man. Even though he'd had problems with his prostate his whole life, and his son was diagnosed with PC at the young age of 53, he couldn't tell you if he's had a recent PSA test, when his last one was, or even what his last numbers were. He left all that up to his doctors. Though he was extremely healthy, in every other respect his whole life, he died from prostate cancer that had metastasized throughout his whole body.
4
A subject too close to home.
I’ve had years of PSA testing and years of biopsies that forewarned nothing.
Doctors who were clueless as to “why” am I going through this.
Who cares? They certainly didn’t. Eventually several TERP operations proved nothing
But left me not the man I could be physically.
This article says absolutely nothing. A total joke by the author and various “experts.
5
My father-in-law died from prostate cancer. He had a diagnosis in his 70s and the doctors told him it was slow growing and unlikely to kill him. Wrong. He died a painful death in his 80s from this disease.
People who say that there is over treatment never talk about the people who suffer from the opposite side, that of no treatment.
14
I have graduated medical school class of 1968 and retired from practicing medicine 20 years ago.
We have an instinctive and cultural drive to find out what the future holds out for us, regardless of possible utility. In medicine SCREENING has become a credo of faith. In reality screening is often valuable, but sometimes superfluous or even harmful.
For instance, Screening for hypertension is unquestionably indicated, there is ample evidence that the earlier treatment is begun, the better the results; The same goes for intraocular pressure, diabetes, and many other conditions. On the other hand for instance, early detection of Alzheimer does not provide any better opportunity for treatment, and provides no utility except to the people administering the test.
As to PSA, I stopped having it tested once I hit age 65, my decision. All personal testimonials do not indicate the level of risk or benefit to a man before he is tested; and most physicians are probably biased in favor of any and all testing modalities. To a person with a hammer everything looks like a nail.
9
You will find a blizzard of contradictory advice about this disease. If you have it, go to websites that rate urologists and hospitals and avoid those with a lot of bad experiences. Hire one that has very high scores and don't insist on a male one. Info on the web is often wrong, obsolete or confusing.
8
PSA screening saved my life. Within a year my PSA went from 2.6 to 4.2; I was 63 years old. My family physician ordered a biopsy and the result was all 6 cores on the left side showed cancer. I had surgery and the pathological report reported stage 3 and extracapular extension and high grade PIN. 12 years later I am cancer free but, without PSA screening, I would have been long dead by now!
14
As a survivor of prostate cancer, I think Ms. Brody overlooks psychological effects on men of these decisions. The "over-testing" concern, using the PSA, while a worthwhile conversation, gave a lot of skittish men cover to not do anything about prostate cancer. It's a part of our bodies we'd rather not have people messing with. The decision-making is really not as linear as one might think.
I was not hiding the fact of my cancer/surgery experience. And a number of men friends confided to me they did not want to know and had no intention of ever getting tested. This, in spite of my telling them, a test is only a test.
In my case, the cancer was borderline aggressive. My doctor asked me the same question my financial planner always asks me: "How long do you plan to live?" It's a great question. And very difficult to answer since I don't control all the factors that determine longevity. I was 62 at the time of initial diagnosis.
I decided not to roll the dice and had it surgically removed while it was still contained. I don't regret the choice. I'm clear now for ten years. A close friend with a similar diagnosis decided to wait. Many men have a reticent approach to active surveillance. Unfortunately, the next time they assessed him, the cancer had leapt into high gear & spread requiring a much more aggressive, debilitating intervention with uncertain outcomes.
15
I would just add that the tone of the article by your health correspondent tends to downplay the danger of prostate cancer for some patients. As one never knows if they are likely to be someone who lives with prostate cancer or dies from it, it makes sense to be careful, and have a DRE as part of the overall process.
5
@Mike Rose The issue is help vs injury from treatment. About one life is saved for each 1,000 people who are screened. Of that 1,000 screened, 50 will be treated and 20 of them will experience incontinence and/or impotence for the rest of their lives. Yet they would not have died of the disease without the treatment.
People say "yes" when asked "do you want to treat this if there's a 1 in 1000 chance it will save your life?"
People say "no" when asked "the treatment has only a 1 in 1000 chance of saving your life, and there's a 40% chance you'll be impotent and/or incontinent for the rest of your life. Do you want to treat?".
It's the same question.
11
@Gordon Prince
That's a ridiculous, dishonest, and manipulative use of statistics. The proper way to frame this is use the number of people who get a "positive result" from a screening, and then work through the numbers of people treated, success rates, incontinence, etc.
I understand that from the medical community's perspective (one of saving money in this era of financial shortfalls), that's one way of looking at things. As an individual, though, it seems dishonest to me and one reason that people have so little trust in doctors.
If you're worried about costs, frame the question in the way I outlined and then tell people they can get the test done themselves. It's costs a mere $31. Then you can have the conversation with patients about success rates, complications, how fast the disease will progress without treatment (i.e. perhaps very slowly), etc.
PSA test:
https://www.lifeextension.com/lab-testing/itemlc010322/prostate-specific-antigen-psa-blood-test
3
@Paul B The US Preventative Services Task Force keeps asserting that none of the screening has any effect on mortality. Which I think is the heart of the issue.
Their recommendation is
1. don't have the PSA test
2. if there's a high number, don't have the biopsy
3. if you have a biopsy and find cancer, don't treat it
That's because according to the science, none of this affects mortality. Urologists make 50% of their income treating prostate cancer, but it doesn't make any difference. Individuals saying they "were saved" almost certainly would still be alive without treatment.
5
Men do indeed still die of prostate cancer when there is metastasis. A simple check for this cancer for men of all ages which is more accurate than the notoriously innacurate PSA is a digital rectal examination or DRE, by which the medical specialist checks the hardness of the prostate, and can conduct further tests if it is hard, like an RMI scan and biopsy. My doctor failed to offer me this simple and inexpensive test when my PSA came back at 4.7 and I was asymptomatic, thinking it was within the normal parameters, and my prostate cancer was diagnosed several months later. The lesson is to ask for the, to put it crudely, "finger up the bum" test. It was painless and not unpleasant and could have caught the cancer earlier, offering me far less anguish than I have endured, and a less aggressive treatment. Luckily, a bone scan revealed no metastasis, but some men are not so lucky, and die from the disease.
11
@Mike Rose
Neither PSA nor DRE are definitive. I had normal DRE but high PSA and cancer. These and other tests are part of a ever-increasing array of diagnostics that should be used in a graded fashion, starting with the least invasive (PSA and DRE) and going to some of the other non-invasive tests (%free-PSA, MRI, 4K, etc.) and then moving to more invasive biopsy if warranted.
PSA testing frequency should be dependent on other factors like age, previous PSA, family history, etc. It should not be an all or none approach and decisions should be made in consultation with a urologist.
My story - At 67 I had a PSA of 4.0. Doctor didn't seem concerned and I had no testing for 3 years. Then last year I had to request a PSA test and it was 15 and the follow-up biopsy Gleason 3+4. Cancer widespread in the prostate and was slightly outside the prostate so more aggressive, non-nerve sparing surgery. Although zero PSA at this point I have a 20-50% chance of reoccurrence.
4
You write that the test was introduced in 1994, but I've always had a high PSA, going back to the 70s. I've even had biopsies which found nothing.
So what blood test was introduced then, and how did it differ from previous tests?
I was successfully treated for pancreatic cancer at Sloan Kettering 13 years ago. I'm sure if there were concerns about my PSA, my annual return visits for a check-up would have alerted my oncologist.
2
Since physicians are now not regularly performing guaiac screening ( which I was taught to do in mefical school) which was one function of a rectal exam , the other being manual examination of the prostate, certainly one would want a PSA; not first discovering Prostate Cancer after experiencing back pain due to metastases to the spine or urinary complaints! Odd reasoning that demands preventive medicine generally applied in so many areas, but not in regards to prostate cancer.
6
I was fortunate to catch my prostate cancer while it was still within the gland in 2011. My PSA jumped up and down for years between 1 and 3. Went to 4.5 then 6. Detailed sonogram was done along with biopsies. They showed a Gleason 7. MRIS was done and showed two tumors. Had a total nerve sparing robotic prostatectomy at Memorial in NYC and PSA is now undetectable. Catch the cancer early and it will not become a vocation for the rest of ones life.
23
This otherwise informative article perpetuates a misconception about how to interpret changes in PSA test results that limits its usefulness. Ms Brody describes a change in PSA test results from 4 to 6 ng/ ml over the course of a year as “ “precipitous”. Admittedly, this is how many people interpret this seemingly large numerical difference.
However, this interpretation overlooks an another interpretation which is equally plausible. Ms Brody alludes to this possibility when describing a range of factors which can influence PSA test results. She mentions “ recent sexual activity, bicycling, benign prostatic enlargement, and inflammation of the prostate” but fails to include another- inherent random variation due to measurement error. This can account for 15 to 20% of the difference between any 2 PSA test results, even when these other factors have been held constant. Therefore, a PSA test results of 4 ng/ ml can be expected to range between 4.8 and 3.2 just due to a 20% measurement error. Likewise, a test result of 6 ng/ml could range between 7.2 and 4.8.
On top of this, the other factors mentioned above ( including changes in diet, which Ms Brody failed to include) could influence the annual test results.
I recently published an article in Oncogen ( Pfadt and Wheeler, 2019,2/2) that documents these assertions and describes a strategy for detecting true “ signals” in such “ noisy” data. I hope your readers and Ms Brody will review it before the next article appears.
17
As my doctor told me, "If a doctor tells you not to have a PSA test, get another doctor."
I had the test and it saved my life.
27
I couldn't agree more! Prior to my husband being diagnosed with prostate cancer last year, I was "brainwashed" by reading all those anti PSA screening articles. Thankfully, his urologist, who was monitoring a slowly rising PSA score every six months, told him it was time to get a biopsy. It showed stage 3&4 tumors in both sides. He was symptom free prior to that. After a radical prostatectomy and 39 sessions of radiation, his PSA score is undetectable, and he is feeling great.
I wish the media would stop publishing all those anti screening articles, or at least have a balanced approach to reporting!
12
I strongly support the testing. It found an aggressive cancer in me, a healthy 64 (at the time) year old man. The position of the lesion was such that it would not have been found by manual examination. The PSA test gave a reading of 107. To give some context, a reading of 10 is considered high. A biopsy revealed the cancer and a prompt surgical intervention saved my life. I think this is a worthwhile test and I have encouraged my male friends to be sure to take it.
One man's opinion ........
34
Something not in the comments so far, and not likely to be mentioned in the second article, is the question of how definitive any "cure" might be, even with early detection.
It was famously asked by a urologist decades ago, in the cases where a cure is possible, is it really needed? And in the cases where a cure is needed, is it really possible? PC was increasingly viewed as coming either in the form you needn't do anything about (non-aggressive) or that you COULDN'T do anything about (aggressive), except relieve late-stage symptoms.
Surgeries declined by the 1970s because it was increasingly believed, thanks to mounting evidence, that prostate cancer was a slow-growing but essentially metastatic disease.
The many years leading up to a clinically significant tumor allowed the cancer to "seed" its cells outside the prostate (typically in the bones) and remain dormant for years. That science is there, for those willing to look.
So many men comment (here and elsewhere) with certainty, saying if they hadn't received early treatment they'd otherwise surely be dead, or saying if only they HAD been screened early, then they surely would have less-advanced disease.
But truthfully, they don't know. Their DOCTORS don't know! If they did, the first thing they'd tell those of us with cancer is EXACTLY what kind of cancer we have and how soon it will kill us (or not). Instead, we are biopsied, graded and placed into a risk-continuum that may or may not reflect eventual outcomes.
40
@noah Thank you for this perspective which is rarely voiced so eloquently.
3
Were it not for screening my Gliesen 7 at age 57 would have progressed until I noticed symptoms and options would have been limited. Avoid screening at your own risk.
25
This is very old news.
And what does “...the prostate and it’s surrounding neighbors” supposed to mean?
4
@Warren
Think "surrounding neighbors" means the anatomy in the local area of the prostrate bed, such as nearby lymph nodes, seminal vesicles, bladder neck. It's distinguished from cancer that has moved further down stream to the bone, etc., ie has metastasized. If it is still deemed localized, it's deemed still curable and can be attacked as such.
Not a doctor, but that's my layman understanding.
2
PSA of 4 is accepted as the point at which there should be further investigation. But men should be aware that it is possible to have aggressive tumors with PSA levels as low as 2. I have a family history, so as I watched my PSA increase from 1 to 2 to 3 in less than 2 years, I decided to do a 4KScore blood test. It was this additional test that alerted us to a problem. Had we waited for the PSA to go over 4 doing the biopsy, the cancer could have potentially reached stage III, and may have been a much more complicated surgery.
13
My GP recommended yearly PSA testing starting around age 50, even though he was a skeptic for many of the reasons mentioned in this article. At age 55, my PSA suddenly increased, so he suggested re-testing six months later, when it doubled to more than 9. A subsequent biopsy found that I had prostate cancer in all 12 of my core samples, some 100% cancerous, with a resulting Gleason score of 7. After follow-up tests to see if the cancer could be detected outside my prostate (it wasn't), and after consulting with two different radiologists and urologists (and an MD-PhD prostate cancer researcher), I elected to have a radical prostatectomy by an experienced urologist who still does open surgeries (not robotically), which while more traumatic for the patient, are more likely to leave "clean" margins and, most importantly to me, an intact neurovascular bundle (which enables erections). Four years later, my PSA is undetectable, my bladder control is only marginally compromised, and my sex life is, if anything, better than before, because my girlfriend and I consider every time we have sex to be a gift. And every time I now see my GP, I thank him for recommending that I have an annual PSA test.
62
Up until 2 years ago at age 67 never had a PSA test.Switched
to a new internist who insisted one be added to a upcoming
blood work up.PSA was 7, six months later up to 10 now a year
later up to 19.Refused a DRE,Prostate Biopsy or further PSA
testing.Feel great,work out daily with free weights,run,BPI of
17.7.If I do have prostate cancer,I don't want to know it.
9
@Lloyd
Llyod's response demonstrates how we uninformed, or mis-informed, men are not being given the information and education we need to make a fully informed decision.
At about age 50 a college friend whom I had been very close to for over 30-years had a "PSA scare" and a prostate biopsy, which resulted in serious adverse side effects and NO sign of cancer. Fifteen-years later, when my PSA was vacillating around 4.5 - 5.5, I took his experience to heart and considered the fact that he stilled showed no signs of prostate cancer. That was a major factor in my decision to do no more testing after age 66.
Here I am 18-months post surgery with recurrent cancer and NO, Absolutely NONE, adverse side effects from the surgery. I am in excellent health, play hard serious racket sports for 10 - 15 hours a week, ride my bicycle a 100-miles a week. It is as if I never had the surgery.
IF - I had known, at age 66 with a PSA ~5.0 or so, that a radical prostatectomy could be done, my future cancer free status assured, and I would have no long term side effects I probably would have considered more PSA testing and more aggressive treatment.
BUT - NO one provided me with that information and ALL I knew was about the really bad experience one of my closest friends had with PSA testing and a prostate biopsy.
Men need to understand the prostate testing and biopsies are not the high risk procedures we think they are. And, prostate cancer treatment can be done with few side effects.
2
@Lloyd good Luck
Let us know how you are doing next year!
4
I read the article and have also reviewed the comments. Nowhere is there mention of a particular recommendation for Black men regarding PSA prostate screening. It is a known fact that Black men have higher incidences of morbidity and mortality from prostate cancer. Here is a link to recent NIH post: https://www.cancer.gov/news-events/cancer-currents-blog/2019/prostate-cancer-death-disparities-black-men
I get disgusted at the continued lack of useful health information that is relevant to and addresses the disparity in care for blacks and people of color. I am 64 yrs old and a pharmacist and hae personally insisted that my primary care physician order an annual PSA test at least since I was 55. I was comfortable initiating the conversation with my PCP but many men will NOT be. You do a disservice when you fail to bring out this important aspect of PSA testing in regards to men of color.
11
@SteveC6393 it actually states in the article,
'PSA screening is a potential benefit for younger men with a strong family history of prostate or related cancers, men who carry a BRCA1 or BRCA2 mutation, and African-American men, who are more likely than others to develop an aggressive prostate cancer. For them, screening is best started at age 40 or 45.'
17
As someone recently diagnosed with aggressive prostate cancer (Gleason score of 9) that has already spread at least regionally, I strongly disagree with the author’s conclusions. I am 66 years old and have been regularly going to doctors for checkups. It was only after I requested a PSA test (that came back 240) that my cancer was found. Now the only treatment options available are aggressive ones. It’s too late for surgery and the best I can hope for is to keep it at bay before it will likely kill me (within 1 to 3 years WITH radiation and hormone therapy). Please ask your doctor for PSA screening if you’re over 60.
41
You are right. They should have tested you sooner. We can make choices if detected earlier. I am so sorry you had to find out later.
All the best.
15
I’ve had a rising elevated psa for about 10 years. It gradually rose from 4-5 and up to its current level. It has stabilized at 10 for about 4 years. Eight years ago I had a biopsy which was negative and three years ago I had an MRI which was negative. My GP and urologist attribute it to BPH, enlarged prostate. It’s still worrisome and confusing what to do moving forward. Also, the biopsy left me with urgency issues which I never had before.
9
@Jeff I've had symptoms similar to yours (PSA up to 11). I recently had the TURP procedure to deal with BPH. The initial indications are that it has been very successful. I'm glad I agreed with the doctor's recommendation to have this procedure.
3
I was one of those who did sporadic PSA testing from age 54 to 62 and then did annual PSA tests from age 62 to 66. My internist, who I had been seeing for 20-years, and I carefully considered the PSA, which ranged up and down from 4.2 to 5.8, back and forth, from age 62 to age 67. We then decided that no additional testing was needed.
At that time I was in excellent health with no co-morbiities and a projected life span into my mid-90s. I had no history of prostate in any first degree relatives.
As I turned 71 my new, younger internist insisted I have another PSA test, which came back at 9.2 then 10.4 six weeks later.
I am now 18-months past my radical prostatectomy. My prostate cancer has now returned because the surgery was not able to remove the cancer cells, which had escaped the prostate gland. I must now go thru 39-days or radiation therapy with a more than 10% chance of severe gastrointestinal side effects, such as diarehha 3 to 5 times a day.
It is most likely that, if I had treated the prostate cancer at age 65 it would have been entirely contained in the gland and I would not now be looking at radiation.
The decision, at age 65 to ignore any additional testing, due to what we thought was a high but stable PSA, was probably inappropriate. And, it is certain I should have continued with Active Surveillance, which would have required at least semi-annual PSA tests.
30
This post supports the need for routine PSA monitoring to detect clinically significant changes in PSA “ kinetics”. ( changes in rates of change over time) as opposed to one shot testing as a form of “ screening”. This later has been debunked many times since PSA testing was first introduced in the 1990s ,while the former is well supported by basic research and routine clinical practice.
I am a research scientist with advanced prostate cancer who recently published an article with Dr Donald Wheeler in Oncogen ( 2019,2/2) that describes how PSA test results should be graphed and interpreted in order to identify meaningful “ signals” in “noisy” data sets.
The article also illustrates how PSA test results, together with changes in associated testosterone levels, can be graphically represented in a manner that facilitates data-based decision making during the course of an individual patient’s treatment.
I look forward to reading part 2 of this series and hope that Ms Brody does a better job of presenting relevant data that she did in this article.
13
@Al Pfadt PhD
Thanks for the heads-up. That looks quite interesting.
Link:
https://www.oncogen.org/full-text/single-subject-studies-in-prostate-cancer-how-graphing-psa-test-results-and-testosterone-levels-using-process-behavior-and-celeration-charts-can-provide-insight-and-guide-clinical-decisions
1
I’m a nurse practitioner and my 58 year old orthopaedic surgeon husband had slacked off on his annual PSA checks. It was only when he needed pre-op clearance for back surgery that his astute internist sent off a PSA in addition to the pre-op labs when she saw that his last PSA was six years ago (he was too busy doing his life to have annual physicals). PSA 12> MRI> large prostate lesion> biopsy> robotic prostatectomy. All I can say is thank G-d. The article oversimplified the matter. Why wouldn’t people err on the side of caution? So you may have to repeat the PSA or you may have anxiety worrying but it’s better than the possible alternative. If it saves a life then it’s worth it.
46
As someone who has been living with PCa for 6 years now there is much to agree with in this article. Active surveillance using color Doppler ultrasound or multiparametric MRI once a year in conjunction with PSA’s done 2-4 times a year can help identify which cancers might be more aggressive and in need of intervention.
Once could argue that 80% of cancers are indolent. But that still means that 20% are more serious. How can a man know if he is one of the 20%?
Other research has found that about 35% of cancers thought to be ‘low risk’ (ie, Gleason score of 3+3) are actually underestimated. Ie, these men have higher risk cancer thanks initially thought. More reason to do active surveillance where changes in the cancer can be spotted more reliably.
Thanks for the info on 4K AMD PHI. I will ask my MD about using these measures in lieu of just the PSA.
6
As the over 70 owner of a large prostate (last measurement >70g) I get high PSA values on all PSA tests. That being said, a follow-up "Free-PSA" reveals that the elevation is not likely to be caused by a malignancy.
Fortunately, my medical care provider keeps me in the program of "Watchful Waiting" which requires watching while waiting.
Since I'm an avid bicyclist and still sexually active I have to observe a protocol days in advance of a blood test to reduce the probability of a spike. A small price to pay to be able to continue to monitor my prostate.
I did have to learn about the prostate and calm down. So, when the baseline numbers appear, they are followed by a Free-PSA which confirms that nothing has changed.
Fear is the main problem that sends some men running to the surgeon. There are also those surgeons that use that fear to bring men into the OR instead of simply watching and waiting.
Lastly a friend who is a Urologist uses MRI's to find masses before ordering biopsies. This is more accurate than ultrasound for finding masses to biopsy.
8
@George N. Wells I'm glad you are keeping an eye on the situation. As a previous commentor said, we can make choices this way instead of either overreacting or ignoring.
Establishing a baseline PSA level when you are younger then looking at deltas between following tests is more useful than an isolated PSA test performed only after you are in your 60's. It helps eliminate false positives. You would think doctors would tell you about how to prepare for the test to also help avoid false positives but I have never had a physician mention that to me. If you self pay for a PSA test is only around $38-$43 dollars. It is not exactly a budget buster for individuals or insurance companies.
Better diagnostic tests for prostate cancer are in the works. Until then, I will rely on my baseline and delta approach to reading PSA test results and bypass the highly unreliable DRE. Even the doctor lucky enough to have long fingers cannot palpate the whole prostate gland.
9
@Mike B
Great advice on the need for baseline testing. I'd expand it to other blood tests as well. I got into trouble some time ago because a CRP result was evaluated as "normal" and other symptoms were not followed up on. Turns out years of cardio exercise has dropped my inflammatory load so low that, even with a 10-fold increase in CRP I'm still in the normal range.
2
@Paul B Thanks for the info. I will spend more time with my cardio excercise.
1
@Mike B Hi mike. Your approach to analyzing the “ deltas” is the basis for the format Dr Donald Wheeler and myself developed in our article published in Oncogen,2019,2/2.
We illustrate how to used these “ moving ranges” to create a process behavior chart that can be used together with another data analytic technology ( celeration charting) to provide a scientifically validated methodology for detecting “ signals” in “ noisy” PSA data sets.
This is a great article.
As a radiation oncologist at a large university, I treat many patients with prostate cancer. Early detection of prostate cancer (and many other cancers) allows for treatment while the cancer is still curable.
That said, my Urology colleagues and I agree that for appropriately selected patients who have undergone a full workup to confirm that they have the least aggressive form of prostate cancer - and are willing and able to return for close follow-up and repeat biopsies - active surveillance is the preferred approach.
A large randomized trial from the UK showed that for men with the least aggressive form of prostate cancer, surgery, radiation plus hormone therapy, and active surveillance had no difference in overall survival. There was a 3% absolute increase in the risk of metastasis when starting with active surveillance, and about half of men ended up requiring treatment - but many of us like those odds and are happy to avoid radical treatment for some patients, and delay treatment (and side effects) for others.
We support PSA testing, but we only want to treat the patients for whom the risks are worth the benefits.
I am optimistic that the field of cancer care is moving toward earlier detection and more personalized treatments, intensifying therapy for more aggressive cancers and de-escalating therapy for others - all with the goal of achieving cure and minimizing side effects.
23
Ms Brody,
Thank you for your article discussing some of the pros and cons of prostate cancer screening and asymptomatic men. As a primary care doctor on the front lines, it is my job to regularly discuss this test with men on, with the goal of helping them make informed decisions that suit their personal values and health goals. This is not easy, and requires presenting information that does not bias the patient one way or the other.
In my experience, the epidemiological statistics you present here are misleading in a way that creates a favorable bias toward screening:
1.”Today 90 percent of prostate cancers are found while the disease is still confined to the gland and its nearby neighbors, when nearly 100 percent of men with the disease survive five or more years.”
This is almost certainly the result of lead time and/or length time biases. Earlier and earlier detection of cancers inflates both the proportion of localized cancers detected, as well as reduces 5-year mortality rate. Neither of these statistics is as relevant to a man than the likelihood that screening will be more beneficial than harmful to him.
2. “the death rate... has dropped by more than half since the PSA was approved”
It is not accepted that screening programs are a significant cause of this. It’s plausible that other factors, like improved treatment options and the observed reduction in a range of types of cancers, which many attribute to meaningful reduction in cigarette use.
Thank you.
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Keep psa testing, the coronavirus will thin the herd enough.
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My stepfather was operated on for PC near 80, but never fully recovered from the surgery and died some months later after blacking out and falling backwards onto a hard floor. Given his poor health, he did not have that many years left, but the operation, as often happens with many surgeries in the frail elderly, reduced his quality of life and shortened it.
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@GeorgeNotBush Important observation. All major surgery presents high risk in the frail elderly. The patient must be clearly informed of this. The operation can be a success but if the patient is frail going in, the likelihood of major decline in quality of life post surgery is huge.
2
Essentially this article weighs anxiety with death. The actual reason the false-positives become fearful is realization of mortality--avoiding a life-saving test to reduce this feeling is absurd.
My excellent health care stopped administering the PSA test routinely. After five years I got an outside check by the VA although completely asymptomatic, and the result was 26 ng/ml.
I am undergoing treatment now and this policy shift may have killed me, but at least I was not anxious while the disease progressed.
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@DRB Anxiety could have been alleviated by more knowledge and treatment.
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I have had elevated PSA levels for the past year. I had a prostrate biopsy and visual examination recently which luckily did not show any presence of cancer. However I am now stuck with my high PSA levels, periodic tests and my periodic anxiety about what else I should be doing. Hopefully there will be more research done to determine other causes for high PSA levels and treatment options to reduce those levels.
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@Peter: continuing high PSA scores following a negative DRE by an experienced urologist followed by a negative random needle biopsy does not address whether you have aggressive prostate cancer in an area of the prostrate gland that cannot be reached by DRE or by a needle biopsy but require T3 MRI then a biopsy superimposing the MRI results on an real time ultrasound to biopsy areas not reachable by needle biopsy or DRE. Waiting with no symptoms despite continuing high PSA scores may result in an undiagnosed advanced, aggressive tumor breaching the prostrate capsule and spreading beyond the capsule.
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Excellent article on the risks/benefits of prostate cancer screening. Still quite controversial, with differing opinions between primary care vs. urology, and younger vs. older physicians.
The manual prostate exam (finger test) is notoriously inaccurate and varies from physician to physician, so do not let your physician rely on that test alone; it should be used in conjunction with PSA testing if screening is pursued. As weird as it sounds, not screening for prostate cancer is valid for some men.
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I've just begun wading into the morass of a cancer-positive prostate biopsy. At age sixty-four, my immediate concern is potential interference with sexual function and urinary incontinence associated with the various treatment options. Today I go in for an MRI, which will hopefully establish a baseline analysis point for future comparative reference. I am not excited to undergo another biopsy procedure ...
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The recommendations for treatment change rapidly and the studies have a mathematical precision and are based on the variables that were available and selected to study. Now add the patients are part of a changing sample as the average age increases. Death is like pregnancy; it doesn't happen in fractions. A professional is a person paid for their judgment. If you are comfortable with the physicians then by accepting their recommendations you are going with the best choice available at the time. Later the treatment options and recommendation will probably have changed.
3
I began to see my PSA rise about 4 years ago, I am now 64. This past Dec when it hit 7 I had a biopsy done and it revealed a mid level cancer, but when seeking a second opinion from Sloan, they reran the samples to raise the score to 7 (aggressive) which was confirmed with a MRI and a score of 4. Now the only path is a Radical Prostatectomy. The lessons learned are no single test is the answer, it is a complete spectrum of tests and analysis that gets the best results. So for me, knowing my PSA was rising alerted me to the problem and has hopefully helped me in dealing with it soon enough. Had I not had the PSA test in the first place I would not be aware of any problems, since even with confirmed advanced cancer, I have absolutely no symptoms.
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@Robert
Prostatectomy is not your only option. Ask to speak to a Radiation Oncologist about their recommendation. Different potential side effects, similar outcomes.
8
Lots of percentages here of how many men don't have aggressive disease, may not need treatment, etc., it is worth remembering that nearly 32,000 men died of this cancer in America last year, a 7% increase from 2018, according to the American Cancer Society. There is a danger in focusing exclusively on the "good" statistics which can lead to a false sense of security about putting off screening.
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This article is a model for informative coverage of a complex health issue. I hope to see it applied to other issues covered in this health section.
3
I had an elevated PSA then afterwards radiation treatment and now 11 years later I am still fine.
But.... I always felt that everyone in the doctor's offices were rushing me to either surgery or radiation for the disease was going to kill me the next day. The most favored surgery was minimal invasive as many in my area had trained for it and wanted to put it into practice (I guess).
The single issue that I wished for but could not get any solid answers was "do I need to do something about the cancer". The consulting doctors gave me a 45 minute conversation, but I wanted to read more about the studies and their conclusions before making a decision. It is very difficult as a layman even with all the technology skills and education that I had. Do I believe available Internet data? Do I beleive doctors who had a financial stake in my case if they performed surgery?
Having other opinions is good but what can you learn when each practice (or location in the US) seems to have a favorite method to treat prostate patients. I have always questioned hard any doctors advice to see why they believe what they believe, however many do not do that.
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@Charleston Yank , Because of exactly what you've just described, once you receive an initial diagnosis of prostate cancer, depending on the severity of the diagnosis, the onus to learn everything you can about the disease, what can be done about it, and what the physical cost of those treatments are, is on you. As this is your life, or at the very least, the quality of your life going forward, that we're talking about, it behooves you to become as much of a lay-expert as you can about the disease, and it's treatments. Only then, when you are reasonably equipped with knowledge about your situation and the options that are available, have a relevant list of questions in hand, and your emotions reasonably in check, should you have additional consultations with your doctor, and with subsequent doctors, about a course of action and treatment.
Prostate Cancer is one disease where most men have the time to learn enough to make educated decisions about how they want to proceed, and what those decisions will mean for the quality of their lives thereafter. Don't blindly let any doctor make that decision for you because you feel the fear that we all do when we hear those words, or worse, because you're lazy, or completely "trust" your doctor. After all, your doctor is in business, and he or she is not the one who will have to live with the aftermath of their decision.
5
Elevated PSA levels a year ago led to a biopsy (positive), an MRI (negative), and another biopsy (positive), and then to radiation treatments. My last PSA was clean. All good.
The unexpected benefit concerned my BPH symptoms, which had been aggravating and worsening for years. And other men who have BPH will agree: it's a real nuisance. As a result of the radiation treatments, however, those symptoms have been drastically reduced. I don't worry about "managing" my fluid intake or making a bathroom stop before going to an event or movie anymore.
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