Brother, eighteen years older was not screened and when prostate cancer was discovered it was untreatable and he soon died. Soon my psa was elevated and biopsy was performed. It’s like a bee sting said the doctor. He was right the first was like a bee sting, he failed to tell me the whole hive was going to sting.) First biopsy negative. Second was positive and surgery, the gold standard was recommended at age 71. That was 21 years ago and at age 92 with no recurrence have stopped taking psas.
Yes the medical industrial complex screens to find cancer. Screening is a big revenue generator of its own, but cancer treatment is an industry with enormous profits. Unfortunately today, with few exceptions, it’s all about money. MRIs are expensive tests.
Exactly what I was thinking. It reflects the sad state of medicine that the first thing that jumps to mind are the financial interests involved rather than anything clinical.
Haha yup. Dr. Mandrola often remarks about being skeptical without being cynical. Sadly, that ship has sailed for me. Hope you have better luck with that.
Alas, I'm in the same boat. I'm skeptical, but definitely cynical. A lot of this behavior goes on in other industries as well, but what galls me the most is the blatant hypocrisy in healthcare about claiming to care about patients, when what what they truly care about is what's in the patients' wallets.
Can you please define/explain your description, "tagged out of healthcare?" Do you mean "almost never use medical care," or you are quite skeptical? Personally I am either a "Medical Nihilist" ("Medical Nihilism" by Jacob Stegenga) or just an "Extreme Medical Skeptic."
Sorry - tagged out of working in it. Sadly I’m tied to healthcare more than I would wish as a consumer simply by nature of birth defects and health issues.
You rhetorically asked: “Why was this study done? Why was it published?” These questions could be asked of virtually all biomarker studies. Those studies almost never look at clinical utility (are the important outcomes, like mortality, better; does it even change treatment?) They are often even underpowered or not for the intended use populations. They typically are of the “gosh, look these things seem (weakly) correlated with those things” kind of science.
This is in my wheelhouse (with my Preventive Medicine board exam coming up). Even USPSTF who are obviously inclined towards maximization only gives it a C. I only order it for patients who ask for it, and I make it clear to men in this age bracket that the procedures and the complications thereof are quite serious.
It all depends on what the meaning of "cancer" is! So much loose language in the CA field. Abnormal cells (visual inspection). "Pre"-cancerous cells. Polyps. Etc.
Problem is that CA, and the truly concerning matter of metastasis, is a complex cascade of genes and mutations and environmental exposures and lifestyle/behavior and immunology. As always, we are trying to "treat" processes we barely understand. Solution: more/better "basic" science research. Slow but steady wins the race!
Prior to MRI, the number needed to screen to save one life was around 1000. Now the number needed to screen (with MRI) is still 1000... it just got a heck of a lot more expensive.
Morbidity would be reduced in either case with selective MRI for risk stratification.
My head is spinning... it's like saying "let's do a study to prove liver biopsy is more accurate than imaging at diagnosing cirrhosis... who wants to sign up to be poked?"
Yes, we can do worse. Mammograms also have a high false positive screenibg rate, often leading to more testing and biopsies and unnecessary treatment for many women. Some recent analyses even estimate that more women are harmed than saved by a mammogram. Even crazier in my view is that the acreening test involves repeatedly radiating tissue that is prone to cancee already. Screening mammograms generate a lot of downstream revenue for hospital systems hence the direct to consumer advertising and mobile mammography units. f you try to respectfully decline, the pressure to participate is coercive. Some women welcome them, so I do not advocate getting rid of them, but it should be optional screening in light of current uncertainties . Would love to hear your thoughts on the current data regarding mammography.
It didn't really speak to Gleason scores - once, or PSA levels. My dad, after his routine yearly tests heard the word, 'cancer' and heard nothing else. He yelled get it out, get it out and went through surgery, complication free, but annoying aftermath conditions. He never really needed it. What about those with high scores who are negative? The group sounded general and random. Why did men drop out? So many questions, and so few answers. But, in the end, someone tell me which of the insurance companies are going to say, "hey, yeah, we'll support MRIs as the first and foremost means of testing. And, while you're at it, do another in a year or so!"
I think the key, in terms of screening for PCa, is serial PSAs every year from say age 35. That way one can track the rise of the PSA (and it will rise as the prostate naturally enlarges with age) and if it accelerates there is a good chance of something going on, which one can then follow up by biopsy (blind or with MRI). Of course this generally requires the patient to keep track of their yearly POSA levels and plot those on a graph (because you know that in most instances, doctors will only look at the current value, and anything less than a PSA of 4 will not be considered worthy of investigation).
In addition, I would note that Adam Cifu is not quite right regarding the sequelae of nerve sparring radical prostatectomy. Long-term incontinence is very rare with current surgical techniques. ED, of course, is much more common but can generally be dealt with. From my own personal perspective I'd prefer to be incontinent and impotent than dead, but that's just me.
My dad is a (retired) urologist and said exactly this. It isn't the absolute value that matters--it is the change and the comparative rate of change that matters. he had done this monitoring on himself and when his PSA skyrocketed suddenly, had a radical prostatectomy.
That was 26 years ago--and he is still living. Watchful waiting would have probably meant death from PC for him.
He says he used to tell his PC patients, "Dead men don't get erections."
Your point that ‘we don’t screen to find cancer, we screen to reduce mortality’ is crucial. It is also something that fails to be understood not only by the vast majority of the general population but also by most doctors, both GPs and specialists. Unfortunately, the ‘test’ has become something of a popular marker for ‘good medical care’ in the population: test=good, more tests=better and more expensive tests=more betterer! I think this is what drives these studies. ‘Why was it done’ is an excellent question, because MRI in this setting (and probably any other), as you point out, fulfils none of the criteria a good screening test requires: it should be cheap, readily available, not overly invasive or unpleasant, find disease that is treatable with methods that are acceptable and that decrease mortality. The ‘it’s nice to know’ doesn’t cut it for screening; never has, never will, as all it leads to is over-investigation and psychosocial/physical morbidity. This study has nothing to contribute to disease screening but is probably all about our obsession and worship of ‘the test’. RIP intelligent clinical medicine.
Obviously it is true that the idea of screening is to reduce mortality. But that's a little bit sloppy in terms of language because we all die eventually (and nothing is more certain than death and taxes!), and the population base one is dealing with comprises predominantly the elderly. More accurately, I think, the idea behind screening is not to reduce mortality per se but to reduce "premature mortality". And the concept of premature mortality has to be assessed on an individual patient basis. For example, let's take two 80 yr olds: one is frail, has congestive cardiac failure and perhaps other things, and is in severe mental decline; the other is fit of mind and body. We do a PSA on them (as part of serial PSAs done yearly) and notice that both have increased rapidly. This leads to a biopsy and both have PCa, and for the sake of argument let's say they both have 3+4 Gleason scores. The question then is what to do. In patient 1, the answer would be nothing because even if you removed the cancer completely (and there were no metastases), the patient would likely die quite soon anyway of causes not related to his PCa, and it isn't evident, therefore, that a radical prostatectomy (or whatever other treatment modality employed) would prolong life or quality of life. For patient 2, however, their life expectancy without PCa might be at least 10-15 years, if not more, and then clearly surgery would be of value as it offers definitive treatment providing the PCa has gone through the prostate capsule. Patient 2 would still die eventually but not of PCa and he would likely die a lot later than if he hadn't had surgery.i.e. patient 2 dying prematurely from PCa would be prevented.
Spot on comment! Unfortunately, as you've pointed out, the "more is better" mentality is pervasive in the lay public, and is, in turn, promoted by a large segment of our medical colleagues.
The popularity of the "more is better" mentality. Especially when you're not paying for it--when it's covered by insurance you're already paying for, and you've met already met your deductible.
I have a friend who when he was 60, his wife said, "Honey, the end of the year is coming, and we've met our deductible, so if there is anything medical you want done, now is the time to do it."
He ended up getting that surgery that cleans out your urethra so you can pee better . . . Determining the net value of that surgery is above my pay grade, but personally I cannot see welcoming voluntary surgery on my dick just because the deductible has been met.
I would like to have some review of thyroid issues/cancer. Any EBM reviews to look at?
Brother, eighteen years older was not screened and when prostate cancer was discovered it was untreatable and he soon died. Soon my psa was elevated and biopsy was performed. It’s like a bee sting said the doctor. He was right the first was like a bee sting, he failed to tell me the whole hive was going to sting.) First biopsy negative. Second was positive and surgery, the gold standard was recommended at age 71. That was 21 years ago and at age 92 with no recurrence have stopped taking psas.
In my case, MRI was never considered and the procedure then in place resulted in satisfactory outcome.
RE: USPSTF grade C ; that’s only after shared decision making which when performed properly and HONESTLY results in most men avoiding screening
Do the authors have stock in MRI machinery?
Yes the medical industrial complex screens to find cancer. Screening is a big revenue generator of its own, but cancer treatment is an industry with enormous profits. Unfortunately today, with few exceptions, it’s all about money. MRIs are expensive tests.
I was thinking the same thing. If you’re going to use imaging to screen for PCa why not use ultrasound? IMO, just as accurate and far less expensive.
Why was the study done?
I’d check the study sponsors. Any relationship to the makers of psa density test, makers of MRI scanners, and/or readers of MRI scans (ie. rads)?
Exactly what I was thinking. It reflects the sad state of medicine that the first thing that jumps to mind are the financial interests involved rather than anything clinical.
Haha yup. Dr. Mandrola often remarks about being skeptical without being cynical. Sadly, that ship has sailed for me. Hope you have better luck with that.
Alas, I'm in the same boat. I'm skeptical, but definitely cynical. A lot of this behavior goes on in other industries as well, but what galls me the most is the blatant hypocrisy in healthcare about claiming to care about patients, when what what they truly care about is what's in the patients' wallets.
Yes indeed I tagged out of healthcare several years ago.
Can you please define/explain your description, "tagged out of healthcare?" Do you mean "almost never use medical care," or you are quite skeptical? Personally I am either a "Medical Nihilist" ("Medical Nihilism" by Jacob Stegenga) or just an "Extreme Medical Skeptic."
Oh and I’m quite skeptical too.
Sorry - tagged out of working in it. Sadly I’m tied to healthcare more than I would wish as a consumer simply by nature of birth defects and health issues.
You rhetorically asked: “Why was this study done? Why was it published?” These questions could be asked of virtually all biomarker studies. Those studies almost never look at clinical utility (are the important outcomes, like mortality, better; does it even change treatment?) They are often even underpowered or not for the intended use populations. They typically are of the “gosh, look these things seem (weakly) correlated with those things” kind of science.
This is in my wheelhouse (with my Preventive Medicine board exam coming up). Even USPSTF who are obviously inclined towards maximization only gives it a C. I only order it for patients who ask for it, and I make it clear to men in this age bracket that the procedures and the complications thereof are quite serious.
It all depends on what the meaning of "cancer" is! So much loose language in the CA field. Abnormal cells (visual inspection). "Pre"-cancerous cells. Polyps. Etc.
Problem is that CA, and the truly concerning matter of metastasis, is a complex cascade of genes and mutations and environmental exposures and lifestyle/behavior and immunology. As always, we are trying to "treat" processes we barely understand. Solution: more/better "basic" science research. Slow but steady wins the race!
Prior to MRI, the number needed to screen to save one life was around 1000. Now the number needed to screen (with MRI) is still 1000... it just got a heck of a lot more expensive.
Morbidity would be reduced in either case with selective MRI for risk stratification.
My head is spinning... it's like saying "let's do a study to prove liver biopsy is more accurate than imaging at diagnosing cirrhosis... who wants to sign up to be poked?"
Yes, we can do worse. Mammograms also have a high false positive screenibg rate, often leading to more testing and biopsies and unnecessary treatment for many women. Some recent analyses even estimate that more women are harmed than saved by a mammogram. Even crazier in my view is that the acreening test involves repeatedly radiating tissue that is prone to cancee already. Screening mammograms generate a lot of downstream revenue for hospital systems hence the direct to consumer advertising and mobile mammography units. f you try to respectfully decline, the pressure to participate is coercive. Some women welcome them, so I do not advocate getting rid of them, but it should be optional screening in light of current uncertainties . Would love to hear your thoughts on the current data regarding mammography.
It didn't really speak to Gleason scores - once, or PSA levels. My dad, after his routine yearly tests heard the word, 'cancer' and heard nothing else. He yelled get it out, get it out and went through surgery, complication free, but annoying aftermath conditions. He never really needed it. What about those with high scores who are negative? The group sounded general and random. Why did men drop out? So many questions, and so few answers. But, in the end, someone tell me which of the insurance companies are going to say, "hey, yeah, we'll support MRIs as the first and foremost means of testing. And, while you're at it, do another in a year or so!"
FREE PSA yeah and the doctor makes money on his drugs.
READ the book "How We Do Harm" it's addresses this ridiculous screening issue. Written by Dr. Otis Brawley!
I think the key, in terms of screening for PCa, is serial PSAs every year from say age 35. That way one can track the rise of the PSA (and it will rise as the prostate naturally enlarges with age) and if it accelerates there is a good chance of something going on, which one can then follow up by biopsy (blind or with MRI). Of course this generally requires the patient to keep track of their yearly POSA levels and plot those on a graph (because you know that in most instances, doctors will only look at the current value, and anything less than a PSA of 4 will not be considered worthy of investigation).
In addition, I would note that Adam Cifu is not quite right regarding the sequelae of nerve sparring radical prostatectomy. Long-term incontinence is very rare with current surgical techniques. ED, of course, is much more common but can generally be dealt with. From my own personal perspective I'd prefer to be incontinent and impotent than dead, but that's just me.
My dad is a (retired) urologist and said exactly this. It isn't the absolute value that matters--it is the change and the comparative rate of change that matters. he had done this monitoring on himself and when his PSA skyrocketed suddenly, had a radical prostatectomy.
That was 26 years ago--and he is still living. Watchful waiting would have probably meant death from PC for him.
He says he used to tell his PC patients, "Dead men don't get erections."
How old was your Dad when he had his radical prostatectomy?
He was 64, IIRC. I forget what his Gleason was.
Your point that ‘we don’t screen to find cancer, we screen to reduce mortality’ is crucial. It is also something that fails to be understood not only by the vast majority of the general population but also by most doctors, both GPs and specialists. Unfortunately, the ‘test’ has become something of a popular marker for ‘good medical care’ in the population: test=good, more tests=better and more expensive tests=more betterer! I think this is what drives these studies. ‘Why was it done’ is an excellent question, because MRI in this setting (and probably any other), as you point out, fulfils none of the criteria a good screening test requires: it should be cheap, readily available, not overly invasive or unpleasant, find disease that is treatable with methods that are acceptable and that decrease mortality. The ‘it’s nice to know’ doesn’t cut it for screening; never has, never will, as all it leads to is over-investigation and psychosocial/physical morbidity. This study has nothing to contribute to disease screening but is probably all about our obsession and worship of ‘the test’. RIP intelligent clinical medicine.
Obviously it is true that the idea of screening is to reduce mortality. But that's a little bit sloppy in terms of language because we all die eventually (and nothing is more certain than death and taxes!), and the population base one is dealing with comprises predominantly the elderly. More accurately, I think, the idea behind screening is not to reduce mortality per se but to reduce "premature mortality". And the concept of premature mortality has to be assessed on an individual patient basis. For example, let's take two 80 yr olds: one is frail, has congestive cardiac failure and perhaps other things, and is in severe mental decline; the other is fit of mind and body. We do a PSA on them (as part of serial PSAs done yearly) and notice that both have increased rapidly. This leads to a biopsy and both have PCa, and for the sake of argument let's say they both have 3+4 Gleason scores. The question then is what to do. In patient 1, the answer would be nothing because even if you removed the cancer completely (and there were no metastases), the patient would likely die quite soon anyway of causes not related to his PCa, and it isn't evident, therefore, that a radical prostatectomy (or whatever other treatment modality employed) would prolong life or quality of life. For patient 2, however, their life expectancy without PCa might be at least 10-15 years, if not more, and then clearly surgery would be of value as it offers definitive treatment providing the PCa has gone through the prostate capsule. Patient 2 would still die eventually but not of PCa and he would likely die a lot later than if he hadn't had surgery.i.e. patient 2 dying prematurely from PCa would be prevented.
The assumption is that the PCa is slowly growing. He could make it to 85 or regardless of the cancer.
But there are more than one types of PCa. I know.
My PSA was normally 3 -4 and very slowly increasing. Age 75, began to have 'normal' pee issues. Had the tube more opening surgery.
Age 77, PSA went to 8. Had intro level biopsy.
Not completely normal but nothing to worry about, the doc said. Pretty much Ok.
Next PSA 18. Whoops! Full scale biopsy.
Dam, cancer in all 6 areas, 2 were 7s.
Very aggressive deadly form. Double dam!
Tested. Still INside prostate!! Yes!!
Got zapped at Mayo. PSA 0 for over 3 years. Peeing 80%. No issues.
Even think about holding my wife very close. :)
Under the 70 and out rule, I would have been dead in 6 or so months and been in misery all the while.
Maybe the MRI would have indicated something amiss much earlier.
I have no health problems; expect to live and love to 90. Why not. (Ok, don't jump on me, that cancer may still be lurking.)
As it now stands, I'd be pushing up daisies.
And I had to fight the local doctors all the time. My usual urologist refused further care, "you're too old".
Then I got with Mayo.
We took a 3-week vacation to Key West April - May and just got back from a trip to Phoenix a week ago. Life is good.
Yes. Be careful what they recommend, limiting care may imply, "dying prematurely from PCa."
Spot on comment! Unfortunately, as you've pointed out, the "more is better" mentality is pervasive in the lay public, and is, in turn, promoted by a large segment of our medical colleagues.
The popularity of the "more is better" mentality. Especially when you're not paying for it--when it's covered by insurance you're already paying for, and you've met already met your deductible.
I have a friend who when he was 60, his wife said, "Honey, the end of the year is coming, and we've met our deductible, so if there is anything medical you want done, now is the time to do it."
He ended up getting that surgery that cleans out your urethra so you can pee better . . . Determining the net value of that surgery is above my pay grade, but personally I cannot see welcoming voluntary surgery on my dick just because the deductible has been met.