I was diagnosed with Prostate Cancer in 2009 following a TURP surgery. The Gleason grade 6 pathology result was considered low grade so my urologist recommended that we choose an active surveillnace approach and that has worked out fine for me. BAsically we look at PSA results each period and decide whether there has been a significant increase since the previous test. So it's the change in PSA that's being monitored not the absolute value. It's instructive to know that my PSA at time of cancer daignosis was 2.0, which is normally considered on the low side.
Counter arguments to "I have definitely saved a life by finding a 50yo with advanced prostate cancer" and "any life saved is worth it". is that this assumes the screening did not cause deaths as well as prevent them. Entirely plausible would be that a man diagnosed with prostate cancer develops severe physical and psychological harm from the diagnosis and may either die from physical side effects of the treatment or even commit suicide. In that case you really could not justify the moral argument that screening is beneficial if it costs as many lives as it saves. So do more men die in the unscreened group than in the screened group from non-prostate cancer causes. JM says that overall mortality is the same "49%" in both groups so yes you might assume any benefit is offset by non cancer deaths. However you really have to look at the decimal places here. Note the graph C is not all cause mortality but other cause mortality. The numbers on the x axis of graph C show that 34,493 of 72,888 screened men died (0.47323) of non prostate cancer related death whilst 42,444 of 89,348 (0.47504) unscreened men died of non prostate cancer related deaths. So there were not more non cancer related deaths in the screened group there were actually less. So PSA screening not only reduces prostate cancer deaths but also reduces other cause deaths by roughly the same number. Screen 89,348 men and you would see 89,348 x 0.002 = 179 lives saved from cancer but you also get 89,348 x (0.47504 - 0.47323) = 162 lives saved from other causes.
I'm a urologist who treats lots of prostate cancer. I can tell you that over the past 25 years, I've come to ignore most mild PSA elevations (<10, let's say). That is unless the digital rectal exam is concerning. I honestly think PSA does far more bad than good. First of all, it is very non-specific. Lots of patients have high PSAs with no cancer, and some of the worst prostate cancers don't have elevated PSAs. Secondly, the risk of death from prostate cancer is exceedingly low. Even with what we urologists call "significant prostate cancer", a man is unlikely to die within 10 years of diagnosis. Personally, I tell my patients that I would rather take my chances than subject myself to a biopsy and definitely treatment, which is often life-changing. So, if it winds up that one day I have metastatic prostate cancer, so be it. There are lots of treatments for that. But I don't feel like being impotent, incontinent, and peeing/pooping blood to (maybe) lower my risk of developing metastatic disease (believe me, many men still progress despite treatment). I find most of my patients feel the way I do and would rather just take their chances. And in terms of this study, it may not be the best. But there are other studies out there as well that corroborate what this study found, and none show a benefit to screening or even treatment for that matter.
Huge omission is that the "control" group wasn't invited to screening, but a huge percentage got it (~50%), and the "screen" group had a large number that didn't. (~60-65% got PSA done). The effect isn't a no PSA vs PSA - its 65% screened vs 50% screened. Imagine if that was the case for colonoscopy. 65% of people we offered colonoscopy to got it done. 50% we didn't offer it to, went and got it somewhere else. The survival benefit we saw was real but small, conclusion: colonoscopy is trash?
Totally ridiculous that people are still referencing this study like it means anything.
Maybe the issue isn't the PSA test (and other diagnostics) but rather is selection bias for the studies. I have no experience in health statistics or epidemiology but do wonder why scientists don't conduct large studies on people with a genetic likelihood of prostate cancer. We know family history and have identified several genetic variants of interest.
It would be great if this was discussed on a future episode.
I am a 56 yo physician and I will not be screened. If PSA screening doesn't stop me dying on a specific day because another condition takes me out on the same day then I'm not interested in swapping one death for another. The "this study is antiquated - if only it were done today it would be positive" approach is deplorable and far too often used by those convinced by intuitive medicine. "If this 10 year old stent trial was done today it would be positive" - how do you know without doing the trial? Presumably 10 years ago they were also saying "if this old study was done today it would be positive" too. And quite often they were not.
PSA is a risk stratifier. Do you consider smoking status when deciding whether to screen for lung cancer? Consider PSA in determining if you get a prostate biopsy, which is the diagnostic test. PSA is the most common cancer in men, and the second most common cause of cancer related mortality in men. If you are diagnosed with prostate cancer, think rationally about the risks and benefits of treatment.
A prostate biopsy nearly killed my dad. He was 80. Picked up a multi-drug resistant infection that resulted in 2 rehospitalizations. He had coded during the biopsy stay. 6 weeks of home IV antibiotics. He was low risk going into the situation, generally lived his life following doctor's orders, but did not overdue it. His "cancer" was never was actively treated and he did not die from it. He lived an additional 7 years in spite of this unwarranted attention. The risks are real.
Most 80 year olds shouldn't be screened for prostate cancer. Most 80 year olds aren't biopsied to help mortality, but find cancers that can wreck their quality of life.
I’m perplexed by this interpretation, but I haven’t read this manuscript yet. In each of the previous updates on ERSPC the number needed to screen and the number needed to treat to save one life kept improving. Initially the number needed to screen was over 700 back in 2014, but by 2023 it was fewer than 300. So I’m curious how it went back up to 500 after decreasing with each update. I’m probably missing something here but seems odd to me
Refs:
de Vos II, Meertens A, Hogenhout R, Remmers S, Roobol MJ; ERSPC Rotterdam Study Group. A Detailed Evaluation of the Effect of Prostate-specific Antigen-based Screening on Morbidity and Mortality of Prostate Cancer: 21-year Follow-up Results of the Rotterdam Section of the European Randomised Study of Screening for Prostate Cancer. Eur Urol. 2023 Oct;84(4):426-434. doi: 10.1016/j.eururo.2023.03.016. Epub 2023 Apr 5. PMID: 37029074.
Hugosson J, Roobol MJ, Månsson M, Tammela TLJ, Zappa M, Nelen V, Kwiatkowski M, Lujan M, Carlsson SV, Talala KM, Lilja H, Denis LJ, Recker F, Paez A, Puliti D, Villers A, Rebillard X, Kilpeläinen TP, Stenman UH, Godtman RA, Stinesen Kollberg K, Moss SM, Kujala P, Taari K, Huber A, van der Kwast T, Heijnsdijk EA, Bangma C, De Koning HJ, Schröder FH, Auvinen A; ERSPC investigators. A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. Eur Urol. 2019 Jul;76(1):43-51. doi: 10.1016/j.eururo.2019.02.009. Epub 2019 Feb 26. PMID: 30824296; PMCID: PMC7513694.
Screening for prostate cancer has a two-fold benefit: First, detection of agressive cancers early when therapy is more effective. It is not ethical to ignore this as part of a "population as whole" concept. Secondly, empowerment of the patient in their own care. Being afraid of complications is an "ostrich in the sand" approach. This paper is using 23 year old data with outmoded therapies and screening startegies. PSA screening is only a first step in providing strategic risk assessment, informed decision making and patient specific treatment such as focal therapy that reduces morbidity and allows intervention should a cancer accelerate while under observation.
I was prescrivere a PSA without being asked. I asked my young doctor to correct the prescrizione. But I am a doctor and know. I fear that many People in Italy are prescrivere without creare consente, and that is not good
As a male physician and one who will be turning 50 next year, I will likely be getting screened. There is a lot of talk about patients worrying if it's positive. Many of of my patients will worry if it's not done. Perhaps that's our fault for pushing screening so much. It is Movember for many after all.
I stopped having PSA tests after reading Ablin's The Great Prostate Hoax. When I saw the announcement of the new study, I wondered whether I should restart. But after reading this excellent analysis, I'm good.
This study compared a population in which 60-65% were screened (typically with higher/annual frequency) vs a population where 50% were screened a few times over the 6 year (I believe) period of the study. There is a survival benefit, but not dramatic. When read poorly, people use it as evidence that PSA screening provides too small a benefit to be useful. The only useful information that most people really take from this is that you don't necessarily need annual PSAs. People getting less regular PSAs did only a bit worse than people who got them more regularly.
The biggest issue that people have with PSAs is a faulty mode of thinking about them. People consider it a diagnostic test with "false positives" and "false negatives". Think about it instead as a risk stratification tool, with the diagnostic test being a biopsy. A good comparison is lung cancer screening. If a patient has a smoking history (risk stratification tool), then do CT ('diagnostic' tool).
My comments are colored by the fact that I had a PSA test at age 63 and it led to further diagnostics that uncovered a cancer that would have killed me had I not had it removed, and I went on to have a very successful surgery. I think Dr. Andrews has a very good point - PSA tests are a part (and only a part) of a successful screening program. I think men should have a PSA test relatively early (earlier if in high risk categories) and periodic retests, since, despite false positives from single observations, a rising level is a pretty good indicator that more is needed. The test is cheap and easy (and people ought to be having regular bloodwork done anyway, so the additional hassle of the test is minimal).
Yes, it is stressful to be told you need further investigation into a potential cancer. But the next steps (further blood work, MRI, biopsies) are pretty simple; the biopsy is no fun, but an MRI-guided biopsy is really good at telling you whether you need further treatment. (This is particularly true if you go to someone who does a trans perineal biopsy not a trans rectal one, a procedure there is no reason to be still being done given the higher risk of infection). Treatments are also really good if you go to a good surgeon - mine had done 1000s, used advanced robotics, and has excellent stats on avoiding bad side effects.
Yes, being told you might have cancer is stressful. You know what else would be stressful? Finding out you have advanced cancer that could have been caught earlier and is now going to be fatal! The "patients will make decisions I disagree with" attitude displayed in many of these comments makes me grateful I had a wonderful MD (who convinced me to get the PSA test) and surgeon who both were excellent at providing me with information and recognizing that the decision on what to do was ultimately mine, rather than ones who arrogantly wanted to restrict information in case I did something they didn't agree with once I had the information.
Dr Andrews has a point… I think that the results apply to the decision of screening populations. In the case of the individual patient I would take a decision based on particular considerations applying to the patient, inform him and let him decide. I usually do not have to order a PSA, but in my own case I would take it due to my age and heredity. When I’m 80 and retired I won’t.
I was diagnosed with Prostate Cancer in 2009 following a TURP surgery. The Gleason grade 6 pathology result was considered low grade so my urologist recommended that we choose an active surveillnace approach and that has worked out fine for me. BAsically we look at PSA results each period and decide whether there has been a significant increase since the previous test. So it's the change in PSA that's being monitored not the absolute value. It's instructive to know that my PSA at time of cancer daignosis was 2.0, which is normally considered on the low side.
Counter arguments to "I have definitely saved a life by finding a 50yo with advanced prostate cancer" and "any life saved is worth it". is that this assumes the screening did not cause deaths as well as prevent them. Entirely plausible would be that a man diagnosed with prostate cancer develops severe physical and psychological harm from the diagnosis and may either die from physical side effects of the treatment or even commit suicide. In that case you really could not justify the moral argument that screening is beneficial if it costs as many lives as it saves. So do more men die in the unscreened group than in the screened group from non-prostate cancer causes. JM says that overall mortality is the same "49%" in both groups so yes you might assume any benefit is offset by non cancer deaths. However you really have to look at the decimal places here. Note the graph C is not all cause mortality but other cause mortality. The numbers on the x axis of graph C show that 34,493 of 72,888 screened men died (0.47323) of non prostate cancer related death whilst 42,444 of 89,348 (0.47504) unscreened men died of non prostate cancer related deaths. So there were not more non cancer related deaths in the screened group there were actually less. So PSA screening not only reduces prostate cancer deaths but also reduces other cause deaths by roughly the same number. Screen 89,348 men and you would see 89,348 x 0.002 = 179 lives saved from cancer but you also get 89,348 x (0.47504 - 0.47323) = 162 lives saved from other causes.
I'm a urologist who treats lots of prostate cancer. I can tell you that over the past 25 years, I've come to ignore most mild PSA elevations (<10, let's say). That is unless the digital rectal exam is concerning. I honestly think PSA does far more bad than good. First of all, it is very non-specific. Lots of patients have high PSAs with no cancer, and some of the worst prostate cancers don't have elevated PSAs. Secondly, the risk of death from prostate cancer is exceedingly low. Even with what we urologists call "significant prostate cancer", a man is unlikely to die within 10 years of diagnosis. Personally, I tell my patients that I would rather take my chances than subject myself to a biopsy and definitely treatment, which is often life-changing. So, if it winds up that one day I have metastatic prostate cancer, so be it. There are lots of treatments for that. But I don't feel like being impotent, incontinent, and peeing/pooping blood to (maybe) lower my risk of developing metastatic disease (believe me, many men still progress despite treatment). I find most of my patients feel the way I do and would rather just take their chances. And in terms of this study, it may not be the best. But there are other studies out there as well that corroborate what this study found, and none show a benefit to screening or even treatment for that matter.
Huge omission is that the "control" group wasn't invited to screening, but a huge percentage got it (~50%), and the "screen" group had a large number that didn't. (~60-65% got PSA done). The effect isn't a no PSA vs PSA - its 65% screened vs 50% screened. Imagine if that was the case for colonoscopy. 65% of people we offered colonoscopy to got it done. 50% we didn't offer it to, went and got it somewhere else. The survival benefit we saw was real but small, conclusion: colonoscopy is trash?
Totally ridiculous that people are still referencing this study like it means anything.
Maybe the issue isn't the PSA test (and other diagnostics) but rather is selection bias for the studies. I have no experience in health statistics or epidemiology but do wonder why scientists don't conduct large studies on people with a genetic likelihood of prostate cancer. We know family history and have identified several genetic variants of interest.
It would be great if this was discussed on a future episode.
I am a 56 yo physician and I will not be screened. If PSA screening doesn't stop me dying on a specific day because another condition takes me out on the same day then I'm not interested in swapping one death for another. The "this study is antiquated - if only it were done today it would be positive" approach is deplorable and far too often used by those convinced by intuitive medicine. "If this 10 year old stent trial was done today it would be positive" - how do you know without doing the trial? Presumably 10 years ago they were also saying "if this old study was done today it would be positive" too. And quite often they were not.
PSA is a risk stratifier. Do you consider smoking status when deciding whether to screen for lung cancer? Consider PSA in determining if you get a prostate biopsy, which is the diagnostic test. PSA is the most common cancer in men, and the second most common cause of cancer related mortality in men. If you are diagnosed with prostate cancer, think rationally about the risks and benefits of treatment.
A prostate biopsy nearly killed my dad. He was 80. Picked up a multi-drug resistant infection that resulted in 2 rehospitalizations. He had coded during the biopsy stay. 6 weeks of home IV antibiotics. He was low risk going into the situation, generally lived his life following doctor's orders, but did not overdue it. His "cancer" was never was actively treated and he did not die from it. He lived an additional 7 years in spite of this unwarranted attention. The risks are real.
Most 80 year olds shouldn't be screened for prostate cancer. Most 80 year olds aren't biopsied to help mortality, but find cancers that can wreck their quality of life.
Why yes. When the 80 yr old doesn't share plans with family members, harm can happen.
I’m perplexed by this interpretation, but I haven’t read this manuscript yet. In each of the previous updates on ERSPC the number needed to screen and the number needed to treat to save one life kept improving. Initially the number needed to screen was over 700 back in 2014, but by 2023 it was fewer than 300. So I’m curious how it went back up to 500 after decreasing with each update. I’m probably missing something here but seems odd to me
Refs:
de Vos II, Meertens A, Hogenhout R, Remmers S, Roobol MJ; ERSPC Rotterdam Study Group. A Detailed Evaluation of the Effect of Prostate-specific Antigen-based Screening on Morbidity and Mortality of Prostate Cancer: 21-year Follow-up Results of the Rotterdam Section of the European Randomised Study of Screening for Prostate Cancer. Eur Urol. 2023 Oct;84(4):426-434. doi: 10.1016/j.eururo.2023.03.016. Epub 2023 Apr 5. PMID: 37029074.
Hugosson J, Roobol MJ, Månsson M, Tammela TLJ, Zappa M, Nelen V, Kwiatkowski M, Lujan M, Carlsson SV, Talala KM, Lilja H, Denis LJ, Recker F, Paez A, Puliti D, Villers A, Rebillard X, Kilpeläinen TP, Stenman UH, Godtman RA, Stinesen Kollberg K, Moss SM, Kujala P, Taari K, Huber A, van der Kwast T, Heijnsdijk EA, Bangma C, De Koning HJ, Schröder FH, Auvinen A; ERSPC investigators. A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. Eur Urol. 2019 Jul;76(1):43-51. doi: 10.1016/j.eururo.2019.02.009. Epub 2019 Feb 26. PMID: 30824296; PMCID: PMC7513694.
Enjoyed this review
Inspired me to look into the evidence more…check out some thoughts here if interested
https://open.substack.com/pub/vageeshjain/p/prostate-cancer-screening-low-value?r=5ivr8m&utm_medium=ios
Screening for prostate cancer has a two-fold benefit: First, detection of agressive cancers early when therapy is more effective. It is not ethical to ignore this as part of a "population as whole" concept. Secondly, empowerment of the patient in their own care. Being afraid of complications is an "ostrich in the sand" approach. This paper is using 23 year old data with outmoded therapies and screening startegies. PSA screening is only a first step in providing strategic risk assessment, informed decision making and patient specific treatment such as focal therapy that reduces morbidity and allows intervention should a cancer accelerate while under observation.
I was prescrivere a PSA without being asked. I asked my young doctor to correct the prescrizione. But I am a doctor and know. I fear that many People in Italy are prescrivere without creare consente, and that is not good
As a male physician and one who will be turning 50 next year, I will likely be getting screened. There is a lot of talk about patients worrying if it's positive. Many of of my patients will worry if it's not done. Perhaps that's our fault for pushing screening so much. It is Movember for many after all.
I stopped having PSA tests after reading Ablin's The Great Prostate Hoax. When I saw the announcement of the new study, I wondered whether I should restart. But after reading this excellent analysis, I'm good.
This study compared a population in which 60-65% were screened (typically with higher/annual frequency) vs a population where 50% were screened a few times over the 6 year (I believe) period of the study. There is a survival benefit, but not dramatic. When read poorly, people use it as evidence that PSA screening provides too small a benefit to be useful. The only useful information that most people really take from this is that you don't necessarily need annual PSAs. People getting less regular PSAs did only a bit worse than people who got them more regularly.
The biggest issue that people have with PSAs is a faulty mode of thinking about them. People consider it a diagnostic test with "false positives" and "false negatives". Think about it instead as a risk stratification tool, with the diagnostic test being a biopsy. A good comparison is lung cancer screening. If a patient has a smoking history (risk stratification tool), then do CT ('diagnostic' tool).
My comments are colored by the fact that I had a PSA test at age 63 and it led to further diagnostics that uncovered a cancer that would have killed me had I not had it removed, and I went on to have a very successful surgery. I think Dr. Andrews has a very good point - PSA tests are a part (and only a part) of a successful screening program. I think men should have a PSA test relatively early (earlier if in high risk categories) and periodic retests, since, despite false positives from single observations, a rising level is a pretty good indicator that more is needed. The test is cheap and easy (and people ought to be having regular bloodwork done anyway, so the additional hassle of the test is minimal).
Yes, it is stressful to be told you need further investigation into a potential cancer. But the next steps (further blood work, MRI, biopsies) are pretty simple; the biopsy is no fun, but an MRI-guided biopsy is really good at telling you whether you need further treatment. (This is particularly true if you go to someone who does a trans perineal biopsy not a trans rectal one, a procedure there is no reason to be still being done given the higher risk of infection). Treatments are also really good if you go to a good surgeon - mine had done 1000s, used advanced robotics, and has excellent stats on avoiding bad side effects.
Yes, being told you might have cancer is stressful. You know what else would be stressful? Finding out you have advanced cancer that could have been caught earlier and is now going to be fatal! The "patients will make decisions I disagree with" attitude displayed in many of these comments makes me grateful I had a wonderful MD (who convinced me to get the PSA test) and surgeon who both were excellent at providing me with information and recognizing that the decision on what to do was ultimately mine, rather than ones who arrogantly wanted to restrict information in case I did something they didn't agree with once I had the information.
Dr Andrews has a point… I think that the results apply to the decision of screening populations. In the case of the individual patient I would take a decision based on particular considerations applying to the patient, inform him and let him decide. I usually do not have to order a PSA, but in my own case I would take it due to my age and heredity. When I’m 80 and retired I won’t.
I agree with John. Asymptomatic without a strong family history of aggressive prostate cancer,
NO PSA.