Justification for "routine" psa testing in males >50yrs.

[gingernut]

I'm led to believe it's routine in the USA, but considering the low specificity of the test, and the implications of A (1/3) false negative, should it be used as a screening tool in an asymptomatic male?

I'd appreciate any scientific answers before I have to confront my well meaning (but perhaps misguided) colleauges.

(Had a look at NICE and SIGN but nothing conclusive).

[gingernut]

thanks GGR

[gingernut]

Anyway, for anyone interested, no we shouldn't.
http://www.cancerscreening.nhs.uk/prostate/pcrmp02.pdf

[obgraham]

Gingernut, this topic is a hot one in the US right now. The evidence suggests that routine PSA screening is not effective in that false positives and the morbidity associated with unnecessary biopsies (as indicated in the story above) outweigh the benefits.

The real questions are: do the cases revealed by PSA screening really need aggressive treatment? And are aggressive prostate cancers adequately detected by routine screening PSA? The evolving answers to both of these is "no".

Unfortunately is is very difficult to stuff these genies back in the bottle. The PSA providers, oncologists, etc., prefer to ignore the evidence that doesn't support them. And everyone who undergoes successful treatment is convinced that they were "saved" by the test.

The bottom line is still simple: we do not yet know how to predict which prostate cancers will be aggressive, and which will sit till you croak of something else.

These three NY Times articles were written by experts in the field:

http://www.nytimes.com/2009/03/19/health/19cancer.html
http://www.nytimes.com/2010/08/03/he...r=1&ref=health
http://www.nytimes.com/2010/03/10/op...mistake&st=cse

[Loose rivets]

Using the PSA as one of the warning lights, is perfectly sound. Treating a reduced flow with Flowmax or some such, without doing anything else, is suicidal in men over 45.

Remember: Prostate Cancer is the second biggest killer of men in the USA. It creeps into the spine just when you relax with "huh, that drug's got my flow better."

Prostate Cancer is "The best kind of cancer to have." Spinal cancer is the one you don't want. The first can lead to the second.

PSA takes a moment of time at the GP's 'office' as they call it here. Digital is something they should do for you anyway. If they don't, ask. If they still don't, go to someone that will.

Watchful waiting is something that should be only done in men that are over 100 years old, and are deaf, blind, and generally mutilated by old age. Yes, I feel strongly about it. It was suggested for me at 67, and I paid for a biopsy here in the US. I had a Gleason of 4+3. (worse than 3+4 for some reason) and was warned to part with my prostate within a couple of months.

It was still connected to my favorite toy, so I elected to go for Brachytherapy. I was a tad past borderline, but I'm glad I did. It really was a free lunch. If it fails, then so beit. So far the PSA down from 8.3 to 1.2.

Here, if I was rich, I'd have gone for a combination of Brachytherapy and External beam. Followed up by Color-Flow scanning . A 97% success rate is claimed. The highest on the planet. But I aint rich. So I'll take the chance that is now supposed to be equal to external beam.

[gingernut]

Thanks Chaps, and thanks for the links Graham. Glad to sy, they're stopping here.

[obgraham]

I figured you'd be along, Rivets, and I accept your case history. All the best to you.

But looking at the "macro" situation, I'm sticking to what I said. We lack good predictive tools in this disease, and screening by blood testing has not panned out.

NOTHING I've said is to suggest that a symptomatic man should not get a timely urologic workup .

[Loose rivets]

PSA. Yes, just one of the warning lights.

"Free PSA" gets the youngsters here confused. Can I have a Free PSA check? No, you have to pay. No, I mean . . .

I have to say that I was concerned that a biopsy might release dangerous cells into the bloodstream. Everyone I asked about it seemed to dismiss the idea. I was particularly interested as one of my oldest friends is having his second biopsy about now.

My GP at home was fairly dismissive about PSA levels in the early stages. He seemed to accept the value of them after treatment. Odd that. As mentioned, with the right funds, I'd go for that Ultrasound 'ColorFlow' system to see what was happening.

I asked if I needed any further investigation, and the surgeon's office just replied with how pleased they were with the latest PSA. I get the distinct feeling that I have been given a huge increase in life-expectancy, but now am on a latter-day kind of watchful waiting.

If this is true, I'm happy with that. There are a lot of younger people out there that need treatment, and to be 3 X 20 + 10, and soaking up precious resources, is really unacceptable when they've slewed the odds in my favor for me.

Just a thought for those considering which route to take: I gather the removal of the prostate after Brachytherapy, is very difficult if not downright impossible.

[Loose rivets]

Having now read the links I'm even more confused. Good job I'm not bothered by it. Mind you, I would be if I could stop the back pain I've had for ten years or so. Perhaps without that, I'd be more gung ho about life. Still, the science interests me, and I see that they seem to think that there is a use for PSA readings post procedure. That seems to tally with what I was told.

The above mentioned friend still plays racquet ball, runs, and has more hi-tec hobbies than one can shake a stick at. At 71, he's got a huge amount to live for. He's also able to soak up medical information well, for a layman at least, and is I'd imagine, really trying to assess what path to take.

[Mac the Knife]

Interestingly enough, I was discussing this with one of our urologists the other day because of a mutual patient who has a persistently raised PSA and who has had 3 negative biopsies.

I think obgraham sums it up very well - "The evidence suggests that routine PSA screening is not effective in that false positives and the morbidity associated with unnecessary biopsies outweigh the benefits"

Our current oncological dilemma is that current screening techniques only allow us to identify "cancer-like" cells - we cannot differentiate between those that will regress or fail to progress and those that will progress aggressively and eventually metastasise.

In the words of Professor Michael Baum, when it comes to cancers (particularly breast and prostate), we cannot tell the difference between a Chihuahua puppy and a Rottweiler puppy - we have to wait for them to grow up (or not).

This is a very active area of research and molecular biology is starting to identify the different genes that are expressed in aggressive and non-aggressive cancers, though this is complicated by the individual immune response to the abnormal cells.

One of our local oncology units is offering a (currently very expensive) genetic analysis of tumours, which looks at 70 genes known to be implicated in tumour aggression and tailoring therapy to fit. Unfortunately the jury is still out as to how effective this is.

But the molecular biologists are getting smarter every year and eventually we should have the diagnostic tools to enable us to predict tumour behaviour more accurately.

Mac

[gingernut]

Hi LR, thanks for your insight, as you're interested in the science, I'll try and explain where I'm coming from. I think I have since answered my own question from the 3rd of August.

I help care for a population of aproximately 12,000 people.

Half of them are men. A third of those men will die of cancer. The 2nd most common cause of cancer in these men, will be prostate cancer. A quarter of those with prostate cancer will die of prostate cancer, the other three quarters will trundle along, with or without treatment, until they are hit by a bus, or as is more likely in my area, Ischaemic Heart Disease.

It's rare in those under 50, it's as common as having a bald head in those over the age of 80 (60%).

The science I'm looking at is screening.

As obsgraham points out, if you have symptoms it's a different ball game. What I'm talking about is actively devoting resources at a "well" population. In other words, when 50 year old Mr Bloggs comes in with his sore toe on a Friday night, should I test him for prostate cancer. Or even better, should I set up a system to actively seek and test men over fifty?

I'm not really interested in looking at the subset with established disease, as I "hand over" these chaps to my learned colleagues in the hospital.

There are probably two tests I can perform....either DRE, or PSA blood testing, and this was my original query, will it save any more of my 6000 men from dying of prostate cancer than if I didn't do it.

The question to screen is based on quite an old criteria, Wilson's criteria. It's been updated recently, but it's probably still apt today...
The Wilson criteria for screening emphasise the important features of any screening program, as follows:

The Wilson criteria for screening emphasise the important features of any screening program, as follows:

• the condition should be an important health problem
• the natural history of the condition should be understood
• there should be a recognisable latent or early symptomatic stage
• there should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific
• there should be an accepted treatment recognised for the disease
• treatment should be more effective if started early
• there should be a policy on who should be treated
• diagnosis and treatment should be cost-effective
• case-finding should be a continuous process

PSA testing falls down on several of these points, mainly because the test doesn't do what it says on the tin, and, at the moment, the progression to the next stage of investigation involves risky unpleasant investigations.

It can be quite easy to dress this sort of stuff up in pseudo-science, but, as obsgraham points out, the "macro" picture is the important one. Sometimes doctors and nurses get a little hooked up on the figures, (don't get me started on cholesterol), thinking more like engineers than pilot's, but the answer to my original question,

does routine psa testing in asymptomatic males >50yrs save lives

then the answer has to be no.

And since my original posting, I've found the evidence to support that.

[Loose rivets]

Despite me being in the aged and treated group, I still find it an interesting thread. I can see that the PSA red warning light is very similar to some of the W/Ls that we inherited on the DC3 after the military had finished with them. Along with drift sights and Vary pistols, there were warning lights that no one knew the function of. One even came on about half way to where we were going - no matter where that was, and no logic could ever be found to account for this. I think PSA figures are probably more illuminating that that.

Not much has been said about Free PSA. As you will know, the numbers work in the opposite direction. Just how good a tool this is I don't know.

I went to have some fluid taken from a specialist in a 'Strip Mall.' Everything seemed quite professional, and the costs were not vast. While the poor soul did a digital, he squished one side of my prostate and, I think at that stage, collected some fluid. He then went to the other side and the dialog went something like: "Now we'll take some from . . . Oh. No need to bother. You need a biopsy. Soon.

I went to a Methodist's Hospital in Texas, and a wonderful surgeon waived a large part of his fees. "I believe if the sun shines on you, you should spread it about." (Sic) but close. I paid for little more than the pathology.

Now here's a thing. So many people have complained of it being painful. It stung slightly, but that's it. Nothing else at all.

Mac, I'm not entirely clear if

only allow us to identify "cancer-like" cells

is referring to the lab's findings after receiving the samples. My Gleason Score of 4 + 3 caused my GP at home to change from advising Watchful waiting, to being admitted for tests within a couple of weeks. The results were spelled out to me to be an indication of a fairly aggressive cancer.

Are even the tests done on a biopsy sample not conclusive?

I had a couple of detailed X rays following (I suppose) a radio-opaque dye injected into the blood. Something like that, anyway. I was told that the cancer was contained.

Since I'd been having severe lower back pain, I really thought that I may have had limited time to put my affairs in order. But no, not connected. I was then sent to Colchester to see someone that would confirm whether or not I was too late for Brachytherapy. I was past the level on the leaflet, but they said go to Southend or (one other place.)

The procedure under Mr Lodge at SEN then required 'Volume Studies." under general anesthetic. I rather thought that very careful mapping of the location and shape was also a good indicator of at least a high probability of the malignancy.

After the seeds had been ordered from Canada, I had to present myself exactly on time. Too late by a number of hours and the seeds are discarded. I turned up, got given Picolax again, and waited. Good stuff that.

Showered at jumped on the gurney. Two minutes later, 'wake up Mr Rivets.' Nothing hurt . . . oh, until I pee'd Then it stung. Next day home, and it was done.

Since then I've filled in a form and sent in the PSAs. My fellow traveler had to rush in for a catheter, however.

Nookie after the event is a tad odd, but after a while I thought I'd been given radioactive batteries. All I need now is a girl with a fetish for old crumblies.

[mmciau]

Prostate Cancer

Here is a helpful site. Various summaries of Prostate examinations


Prostate Cancer Survivors - PSA between 5 and 10 at Diagnosis


Mike

[Rory Dixon]

Some problems of cancer screening

gingernut,
I almost totally agree to your post. Just one thing:
you stated: 'There are probably two tests I can perform....either DRE, or PSA blood testing, and this was my original query, will it save any more of my 6000 men from dying of prostate cancer than if I didn't do it.'
If you really go for this question, the true answer will be 'yes'. This is, because you will most certainly find a few men in your population, where you catch a prostate cancer at an earlier stage which might be cured. Unfortunately, some otherwise healthy will die or suffer due to the performed tests. Thus, the question rather should be (for a screening environment, where you look for healthy people):
...will after performing the test (and all what this test then implies, like biopsies, surgery ... causing adverse events) reduce the rate of deaths in my cohort.
For sure, for the person with an early diagnosis and cure screening is good, but for the one suffering major adverse events for wrong positive test results, it's no good. Only the effects of screening to an entire population or cohort, but not to the single individual, are relevant for the question you have raised.
PSA is very unspecific, this type of cancer has a very pronounced variability, and screening with PSA will provide significant lead-time bias, length-time bias, and overdiagnosis bias. Taking all that togehter, your conclusion is absolutely justified.
If I recall right, there was an interesting article in The Lancet, I think in 2002, 'How we cured symptomless prostate cancer'. The botomline was: yes, symptomless prostate cancer exists (and many man die with it, but not from it), but with a positive PSA finding, these patients will never again be symptomless. They have a cancer diagnosis. And that is the true burden of PSA testing.

[gingernut]

Thanks Rory, interesting post.

Guess I'll stand by my earlier post that psa screening in asymptomatic men doesn't work.

[cavortingcheetah]

But what is a positive PSA finding? Is there such a thing?
Surely the PSA trend over time, the rate of escalation, DREs and any ancilliary information such as prostatic inspection during cyctoscopy should be or could be used to determine whether a biopsy would be adviseable.
Once a biopsy and perhaps a second opinion on that confirm cancer then a decision has to be made as to whether to do anything and if anything is to be done then what to do?
The prostate problem seems to me to be threefold.
Firstly at what stage does one decide to have one biopsy, two biopsy three or four, given that in anything other than a 22/24 core a negative is only a ponderable.
Secondly of course what to do if a positive Gleason is confirmed.
Thirdly and since no one wants to risk one or both of the usual possible prostatic treatment side effects, how can one determine the rate of mestasis of any cancer. There's not a lot of point in excising the gland if the cancer is so slow moving that something else will get you and if you live for long enough, medical science might have developed a painless cure?
Even if you have a radical prostectomy it seems to me that you're very much in the hands of the surgeons and the nerve sparers. In that regard, MD Anderson in Houston comes highly recommended. I think you need to budget around $100,000 for the whole two months down there but the man I know who did thinks that every $ was a bargain.

[Loose rivets]

Having a SIL that spent $144,000 on a FOUR HOUR procedure, that hundred grand sounds like a bargain.

(Spinal surgery through the neck, just four hours away from HOU.)

[411A]

The evidence suggests that routine PSA screening is not effective in that false positives and the morbidity associated with unnecessary biopsies (as indicated in the story above) outweigh the benefits.

This is the opinion of my physician, and he is an expert in the field.
PSA...far from satisfactory.

[stilton]

Just in case you haven't heard of it and are looking for natural relief via
the Herbal route I cannot recommend 'Saw Palmetto' enough.

[twentygrand]

I started having annual PSA tests about 5 years ago. I was spooked by so many of my friends who had prostate problems. I am aware of the limitations of the PSA test, but I wanted (with the agreement of my GP) to set a baseline for my PSA level (currently about 1.7). I will be 70 next year.
I've no symptoms as yet but I want to keep an eye on things!