i'm taking advantage of the assembled mass of medical knowledge that has fleshed out the screening paradigm, i.e. asymptomatic search for disease, to look at a different kind of gray area: the protocol for that search in cases where urological symptoms suggesting enlarged prostate.
Making myself the guinea pig, i relatively suddenly manifested urinary urgency at 64. So at my next health exam maybe 6 or 9 months out a DRE confirms big prostate (which I had already intuited by then). Get a PSA test of 7.2. Sent to urologist says biopsy. I say: gee, thats not really that high and BPH is a thing, I think the literature says there's 25% chance I've got prostate cancer. Would an MRI be a good first step? Urologist: OK MRI and recheck PSA.
PSA stable 7.4. Symptoms bearable and unchanging. Between bloodwork appointments approvals etc. this whole thing stretches out another couple years but the MRI of a couple months back shows no consolidated mass.
By this point I've got a concierge doctor I really like. Very affordable, belies the toni label. Very candid. Has Adam's perspective on prophylactic PSA. She reads the MRI results as: cancer not a significant worry. But the urologist reads it as: well there is no particular area we want to biopsy but we should still do a wideranging biopsy. (And he sneers at the distinction between rectal and perineal biopsy cause everybody has been taught rectal over the last 30 years and they currently try to limit infection risk by testing for resistant bacteria in you bowel biome. maybe that makes sense but some advocates are trying to bring back perineal as better access and less infection risk . . . different thread but urologist says 1% infection rate and 1/2% for rectal biopsy, champions of perineal say 6% and 3%).
At the same time I have a friend who was asymptomatic but had a mildly elevated PSA, still single digits, but got biopsy and had prostate cancer that had already metastasized. This is at least the anecdote of some modest segment. Ironically, his is not a case where screening prevented advanced disease. But I do see testimonies here to some small but perhaps not insignificant sample where early stage is caught. Still not sure what the metrics are, tumor DNA, speed of cancerous growth or spread that define the difference between aggressive and less prostate cancer.
My strategy for now is monitor PSA more frequently because just having a big prostate is not itself a cancer risk from what I can see. I'm already dealing with symptoms and shared decision framework, including shared input from several docs, specialist and general. So I don't have a lot of anxiety over aggressive PSA monitoring.
And one thing I notice in all this grappling with Prostate Cancer screening and risk is it tends to consign BPH to the status of treat the symptoms if they worsen. While there is some research work that seems to debunk the popular notions of taking iodine or boron vitamin d or (insert supplement of the day) there doesn't seem to be much dietary/nutrition or medical advice on how to limit or reverse BPH if there is such a thing. And trying to search for that, virtually all I get are Prostate Cancer discussions.
While the MRI says my prostate is 3 times average (90 cc vs 30cc) and that seems to be on the high side of the phenomenon, I had no personal baseline, and since the symptoms haven't changed in 3 years I can only guess the condition has plateaued or it has threshold effects that haven't kicked in even if it has continued to enlarge over this 3 years. The only conscious change I have made is to eat less, not because of BPH but because my wife died (metastasized serous uterine cancer, another sideways cancer interest for me) and becoming more concerned about how I looked to the rest of the world I determined I wanted to manifest a fit man who used to be old rather than an old man who used to be fit and so I lost 25 lbs. No idea if this had any effect on the pathway of BPH.
Well, that was impolitely long comment but, besides BPH, I'm also plagued by logorrhea.
Population data must be applied at the individual level with active engagement in shared decision's making. While not a scientific observation I will say I know a lot more people who died from prostate cancer vs with it.
Thank you once again for the nuanced discussion. My spouse was recently diagnosed with metastatic prostate cancer at 62. He hadn't had a PSA test in any recent years. His doctor hadn't recommended it, I guess. But I still agree with your points and that the whole screening issue is indeed complex, with important trade-offs. I recall some years ago being called back on a mammogram over a finding which came to nothing, but I was out of pocket several hundred dollars and it caused me a great deal of stress.
Fine theoretical cohort discussion until you become the patient yourself. A vigilant GP ordered me to do a PSA test after years of neglect. My PSA was lowish (6), the prostate cancer though was aggressive (Gleason 9, stage 3). I underwent 24 months of 1st and 2nd generation ADT plus radiation 6 months into the treatment. Now, 30 months later, I am in full remission and again fully active.
My conclusion: in the case of prostate cancer, efficacious and relatively cheap treatment is available if the cancer is caught early. Don't skimp on a yearly supercheap PSA test. Treating full blown metastatic prostate cancer is expensive and not efficacious, and the patient has horrid life end. A no-brainer, really.
What the guidelines on prostate cancer screening stopping at age 70 ignores is the individual's health and his likelihood of living beyond the average. Your patient was probably not told about how severe and miserable the complications of metastatic prostate cancer can be. I had my prostate removed seven years ago while the cancer was in situ, no chemo or radiation required. I am STILL screened annually with PSA as an excellent screen that there is no a low possibility prostate metastasis lurking and reproducing somewhere in my body. By the way, prostate biopsies are uncomfortable but definitively NOT DANGEROUS. Before my prostatectomy, yes there was a tedium with repeat MRIs and repeat biopsies. Despite tolerable urinary incontinence and virtual impotence, I am generally pleased with the outcome.
Hey, give me more credit than "Your patient was probably not told about how severe and miserable the complications of metastatic prostate cancer can be." ;-)
One issue I continue to reflect on while trying to process the complexity of cancer screening decisions is that we are now better with treatment, shrinking the pool of folks who might benefit by pre-clinical diagnosis. This fact lends strength to the argument that an effective screening test must demonstrate a decrease in overall mortality to be considered worthwhile.
The topic of this post has haunted me for the last 12 years, and I know I’ve written about it in the comments. I have come around to understanding your reasoning, but still regret that my husband was diagnosed at end stage for lung cancer at 55 years old. At the time it was happening I was all in favor of yearly full body scans for everyone. If you find it you can treat it. It’s not that his primary care doctor didn’t do any testing at all, just not the one that may have found it….a CT scan. What I will never know is when did it go from stage one to stage four? When would have been the right time for the scan. Would there have been a time even at CT scan would have missed it? I used to joke that had he been a smoker they’d have put him right into that machine and maybe he’d have had a chance. Then I used to say, make sure you have at least one risk producing habit that will get you the screening. Now I know that if there is only a two percent chance that a very trim, fit, healthy, nonsmoking man could get lung cancer at stage four, all in that group have an equal chance of getting it, and it happened to be my husband. He was the “lucky” two percent. The only person who cried as much as we did was his primary care doctor.
It depends on how much agony the metastatic cancer brings to him in the next years. Only then can you feel comfortable with the "enjoyment" of his 70s.
I think that the patient should be part of an informed decision as long as we have strong evidence of what to do if the test is positive (applies to prostate cancer but not to coronary CT for example). We present the facts of what we know and don’t and the patient should decide. Guidelines are written to treat populations, and are after all guidelines, not rule of law.
It’s kind of strange to know that I’m in the likely sunset of life assuming I have 15-20 more years to live in this body (more realistic to think 10-15). I want quality over quantity every day of the week and twice on Sunday. Things you never think about as a youngster become thought provoking as we age…ahh, youth. It’s wasted on the young!
The title and preview of this post has finally made me a subscriber. I do wonder about a different angle. Early identification by screening could find patients eligible for thoughtful, well-designed clinical trials to reduce prostate cancer specific mortality. I am agnostic to the intervention. Diet, drug, exercise, etc. Whatever works, works.
This was absolutely spot on! I’m a 72 year old whose PCP tried to coerce me into having a PSA in my late 60’s by threatening to fire me as a patient if I didn’t. So much for patient counseling, informed consent, and mutuality of decision making. Thank you for confirming my choice of treatment, or should I say non-treatment, that I arrived at myself, in spite of the PCP.
When he threatened you, you should have HIM. There are plenty of PCPs who won't force PSA tests down your throat--especially when you were close to the age when the USPTF recommends against the test.
A method I have used is to get my own blood panel (minus the PSA test) and hand the blood panel results to the PCP.
You've written this comment so subtly!--But I *think* you're expressing my point of view, that I can't imagine a universe in which a male president of the United States over 40 doesn't have careful prostate cancer screening, guidelines or no guidelines. But I am also reluctant to call anyone a liar, so I remain flummoxed and skeptical.
For me, it boils down to a simple question: if I undergo the screening, will there be a measurable increase in my life expectancy? According to the best science we have (thanks, Sensible Medicine), the answer is no. I find this kind of liberating. By following the evidence, I worry a lot less and can spend more time enjoying life, rather than hanging out in healthcare clinics. Avoiding cancer screening is not a matter of gambling; it’s part of maximizing happiness.
My concern right from the beginning about the USPSTF recommendation on screening PSA's (and their recommendations in general) is that it's a static one, not taking into account evolving management as urologists learn to deal with mildly elevated PSA's in individual patients. Watchful waiting is now a much more common strategy as is MRI for evaluation. Good medical care should not be reliant on formulas and protocols.
Mildly elevated PSA - I would put in the range of about 4-10. Could well be just BPH. But it's not a fixed number. You have to take all the clinical circumstances into account. What's the physical exam show? What's the general medical status of the patient? If we have previous PSA's what's the rate of increase, if any? Lots of other stuff.
I'm an internist but from my observation urologists, and other docs too, have over time learned, and are continuing to learn, which patients with an abnormal screening test need to be aggressively evaluated and managed and which can be managed conservatively particularly with "watchful waiting". And of course the patient makes the decision but with urologist counseling.
Moreover there's pretty dramatic increasing use of MRI over the past few years in evaluation of suspected prostate cancer. This has helped to avoid biopsy and to make much better assessment of the management approach.
The USPSTF made it's pretty negative PSA recommendation in 2018, saying it shouldn't be used for screening in men over 70, and it was based on management being done at that time, but a lot has changed since then. I don't think it holds true any longer. I actually didn't think it was right when it came out because I anticipated that things were changing. Neither did the AUA who came out against it.
And although prostate cancer in older men is conventionally supposed to be more benign and slow growing, it's actually pretty devastating in men over 75 with the great majority of prostate cancer deaths occurring in that age group.
i'm taking advantage of the assembled mass of medical knowledge that has fleshed out the screening paradigm, i.e. asymptomatic search for disease, to look at a different kind of gray area: the protocol for that search in cases where urological symptoms suggesting enlarged prostate.
Making myself the guinea pig, i relatively suddenly manifested urinary urgency at 64. So at my next health exam maybe 6 or 9 months out a DRE confirms big prostate (which I had already intuited by then). Get a PSA test of 7.2. Sent to urologist says biopsy. I say: gee, thats not really that high and BPH is a thing, I think the literature says there's 25% chance I've got prostate cancer. Would an MRI be a good first step? Urologist: OK MRI and recheck PSA.
PSA stable 7.4. Symptoms bearable and unchanging. Between bloodwork appointments approvals etc. this whole thing stretches out another couple years but the MRI of a couple months back shows no consolidated mass.
By this point I've got a concierge doctor I really like. Very affordable, belies the toni label. Very candid. Has Adam's perspective on prophylactic PSA. She reads the MRI results as: cancer not a significant worry. But the urologist reads it as: well there is no particular area we want to biopsy but we should still do a wideranging biopsy. (And he sneers at the distinction between rectal and perineal biopsy cause everybody has been taught rectal over the last 30 years and they currently try to limit infection risk by testing for resistant bacteria in you bowel biome. maybe that makes sense but some advocates are trying to bring back perineal as better access and less infection risk . . . different thread but urologist says 1% infection rate and 1/2% for rectal biopsy, champions of perineal say 6% and 3%).
At the same time I have a friend who was asymptomatic but had a mildly elevated PSA, still single digits, but got biopsy and had prostate cancer that had already metastasized. This is at least the anecdote of some modest segment. Ironically, his is not a case where screening prevented advanced disease. But I do see testimonies here to some small but perhaps not insignificant sample where early stage is caught. Still not sure what the metrics are, tumor DNA, speed of cancerous growth or spread that define the difference between aggressive and less prostate cancer.
My strategy for now is monitor PSA more frequently because just having a big prostate is not itself a cancer risk from what I can see. I'm already dealing with symptoms and shared decision framework, including shared input from several docs, specialist and general. So I don't have a lot of anxiety over aggressive PSA monitoring.
And one thing I notice in all this grappling with Prostate Cancer screening and risk is it tends to consign BPH to the status of treat the symptoms if they worsen. While there is some research work that seems to debunk the popular notions of taking iodine or boron vitamin d or (insert supplement of the day) there doesn't seem to be much dietary/nutrition or medical advice on how to limit or reverse BPH if there is such a thing. And trying to search for that, virtually all I get are Prostate Cancer discussions.
While the MRI says my prostate is 3 times average (90 cc vs 30cc) and that seems to be on the high side of the phenomenon, I had no personal baseline, and since the symptoms haven't changed in 3 years I can only guess the condition has plateaued or it has threshold effects that haven't kicked in even if it has continued to enlarge over this 3 years. The only conscious change I have made is to eat less, not because of BPH but because my wife died (metastasized serous uterine cancer, another sideways cancer interest for me) and becoming more concerned about how I looked to the rest of the world I determined I wanted to manifest a fit man who used to be old rather than an old man who used to be fit and so I lost 25 lbs. No idea if this had any effect on the pathway of BPH.
Well, that was impolitely long comment but, besides BPH, I'm also plagued by logorrhea.
Population data must be applied at the individual level with active engagement in shared decision's making. While not a scientific observation I will say I know a lot more people who died from prostate cancer vs with it.
Thank you once again for the nuanced discussion. My spouse was recently diagnosed with metastatic prostate cancer at 62. He hadn't had a PSA test in any recent years. His doctor hadn't recommended it, I guess. But I still agree with your points and that the whole screening issue is indeed complex, with important trade-offs. I recall some years ago being called back on a mammogram over a finding which came to nothing, but I was out of pocket several hundred dollars and it caused me a great deal of stress.
Fine theoretical cohort discussion until you become the patient yourself. A vigilant GP ordered me to do a PSA test after years of neglect. My PSA was lowish (6), the prostate cancer though was aggressive (Gleason 9, stage 3). I underwent 24 months of 1st and 2nd generation ADT plus radiation 6 months into the treatment. Now, 30 months later, I am in full remission and again fully active.
My conclusion: in the case of prostate cancer, efficacious and relatively cheap treatment is available if the cancer is caught early. Don't skimp on a yearly supercheap PSA test. Treating full blown metastatic prostate cancer is expensive and not efficacious, and the patient has horrid life end. A no-brainer, really.
What the guidelines on prostate cancer screening stopping at age 70 ignores is the individual's health and his likelihood of living beyond the average. Your patient was probably not told about how severe and miserable the complications of metastatic prostate cancer can be. I had my prostate removed seven years ago while the cancer was in situ, no chemo or radiation required. I am STILL screened annually with PSA as an excellent screen that there is no a low possibility prostate metastasis lurking and reproducing somewhere in my body. By the way, prostate biopsies are uncomfortable but definitively NOT DANGEROUS. Before my prostatectomy, yes there was a tedium with repeat MRIs and repeat biopsies. Despite tolerable urinary incontinence and virtual impotence, I am generally pleased with the outcome.
Hey, give me more credit than "Your patient was probably not told about how severe and miserable the complications of metastatic prostate cancer can be." ;-)
One issue I continue to reflect on while trying to process the complexity of cancer screening decisions is that we are now better with treatment, shrinking the pool of folks who might benefit by pre-clinical diagnosis. This fact lends strength to the argument that an effective screening test must demonstrate a decrease in overall mortality to be considered worthwhile.
So true. We wrote this article a while back and I don’t think we gave that enough consideration.
https://pmc.ncbi.nlm.nih.gov/articles/PMC6614217/
Thank you for listening, by the way. It helps me.
The topic of this post has haunted me for the last 12 years, and I know I’ve written about it in the comments. I have come around to understanding your reasoning, but still regret that my husband was diagnosed at end stage for lung cancer at 55 years old. At the time it was happening I was all in favor of yearly full body scans for everyone. If you find it you can treat it. It’s not that his primary care doctor didn’t do any testing at all, just not the one that may have found it….a CT scan. What I will never know is when did it go from stage one to stage four? When would have been the right time for the scan. Would there have been a time even at CT scan would have missed it? I used to joke that had he been a smoker they’d have put him right into that machine and maybe he’d have had a chance. Then I used to say, make sure you have at least one risk producing habit that will get you the screening. Now I know that if there is only a two percent chance that a very trim, fit, healthy, nonsmoking man could get lung cancer at stage four, all in that group have an equal chance of getting it, and it happened to be my husband. He was the “lucky” two percent. The only person who cried as much as we did was his primary care doctor.
So sorry.
“He was able to enjoy his 70s, not knowing he was a cancer patient and not having to spend time with urologists or radiation oncologists.”
This one beautiful, pithy sentence, sums up the argument against screening. The expression “overdiagnosis” just doesn’t have the same effect.
It depends on how much agony the metastatic cancer brings to him in the next years. Only then can you feel comfortable with the "enjoyment" of his 70s.
🙏
I think that the patient should be part of an informed decision as long as we have strong evidence of what to do if the test is positive (applies to prostate cancer but not to coronary CT for example). We present the facts of what we know and don’t and the patient should decide. Guidelines are written to treat populations, and are after all guidelines, not rule of law.
Absolutely. Guidelines are only guidelines.
It’s kind of strange to know that I’m in the likely sunset of life assuming I have 15-20 more years to live in this body (more realistic to think 10-15). I want quality over quantity every day of the week and twice on Sunday. Things you never think about as a youngster become thought provoking as we age…ahh, youth. It’s wasted on the young!
The title and preview of this post has finally made me a subscriber. I do wonder about a different angle. Early identification by screening could find patients eligible for thoughtful, well-designed clinical trials to reduce prostate cancer specific mortality. I am agnostic to the intervention. Diet, drug, exercise, etc. Whatever works, works.
This was absolutely spot on! I’m a 72 year old whose PCP tried to coerce me into having a PSA in my late 60’s by threatening to fire me as a patient if I didn’t. So much for patient counseling, informed consent, and mutuality of decision making. Thank you for confirming my choice of treatment, or should I say non-treatment, that I arrived at myself, in spite of the PCP.
When he threatened you, you should have HIM. There are plenty of PCPs who won't force PSA tests down your throat--especially when you were close to the age when the USPTF recommends against the test.
A method I have used is to get my own blood panel (minus the PSA test) and hand the blood panel results to the PCP.
Anyone whose job is responsible for the safety of others has a differential screening.
You've written this comment so subtly!--But I *think* you're expressing my point of view, that I can't imagine a universe in which a male president of the United States over 40 doesn't have careful prostate cancer screening, guidelines or no guidelines. But I am also reluctant to call anyone a liar, so I remain flummoxed and skeptical.
For me, it boils down to a simple question: if I undergo the screening, will there be a measurable increase in my life expectancy? According to the best science we have (thanks, Sensible Medicine), the answer is no. I find this kind of liberating. By following the evidence, I worry a lot less and can spend more time enjoying life, rather than hanging out in healthcare clinics. Avoiding cancer screening is not a matter of gambling; it’s part of maximizing happiness.
My concern right from the beginning about the USPSTF recommendation on screening PSA's (and their recommendations in general) is that it's a static one, not taking into account evolving management as urologists learn to deal with mildly elevated PSA's in individual patients. Watchful waiting is now a much more common strategy as is MRI for evaluation. Good medical care should not be reliant on formulas and protocols.
"not taking into account evolving management as urologists learn to deal with mildly elevated PSA's in individual patients"
Can you specify what these "management" techniques are for "mildly elevated PSAs?." What is the "Number Needed to Treat" for a "mildly elevated PSA?
Mildly elevated PSA - I would put in the range of about 4-10. Could well be just BPH. But it's not a fixed number. You have to take all the clinical circumstances into account. What's the physical exam show? What's the general medical status of the patient? If we have previous PSA's what's the rate of increase, if any? Lots of other stuff.
I'm an internist but from my observation urologists, and other docs too, have over time learned, and are continuing to learn, which patients with an abnormal screening test need to be aggressively evaluated and managed and which can be managed conservatively particularly with "watchful waiting". And of course the patient makes the decision but with urologist counseling.
Moreover there's pretty dramatic increasing use of MRI over the past few years in evaluation of suspected prostate cancer. This has helped to avoid biopsy and to make much better assessment of the management approach.
The USPSTF made it's pretty negative PSA recommendation in 2018, saying it shouldn't be used for screening in men over 70, and it was based on management being done at that time, but a lot has changed since then. I don't think it holds true any longer. I actually didn't think it was right when it came out because I anticipated that things were changing. Neither did the AUA who came out against it.
And although prostate cancer in older men is conventionally supposed to be more benign and slow growing, it's actually pretty devastating in men over 75 with the great majority of prostate cancer deaths occurring in that age group.