Patients, presidents, PSAs, and prostate cancer

When people get sick despite following guidelines

VG is an 82-year-old man who presented with abdominal pain. Imaging revealed widespread metastatic cancer with omental studding. Before a tissue diagnosis, tumor markers — CEA, CA19-9, PSA, AFP — were sent. The PSA was elevated at 569 ng/mL (normal: 0-4). After a biopsy, he was definitively diagnosed with metastatic prostate cancer.

VG had received prostate cancer screening, in the form of yearly PSA tests, for 14 years, from age 56 to 70. During this time, his PSA ranged from 0.8 to 1.2; the last was 1.0. At a clinic visit 12 years before the admission, when he was 70, his primary care doctor documented a discussion about discontinuing screening. The doctor had explained that PSA screening was probably no longer worthwhile, that the harms outweighed the benefits. The doctor reasoned that VG’s life expectancy (given his age and other medical problems) was less than 10 years and noted that the USPTF does not recommend PSA screening in patients over 70. VG said he understood the reasoning and was fine with discontinuing PSA checks.

VG is an amalgam of a few patients that I have been planning to write about. Then, on May 18^th, we got news that makes this essay seem “ripped from the headlines.”