No psa for me. Have seen too many complications from prostate biopsies and prostate cancer surgery in patients and friends. Should have said I wish there was no psa for me LOL - my doctor still orders it and I understand. Tasking the pcp with having a discussion with patients on such a nuanced topic is ridiculous in my opinion. Many pcps will conclude that doing the test and having the urologist discuss the options with the patient if it is elevated is the only sane approach. At least until the PSA is taken off the screening menu. see Merenstein case (Virginia, ~2003–2004). A resident discussed PSA pros/cons with a patient and did not order the test. A jury did not find the physician negligent, but the residency program was reportedly hit with about a $1 million verdict. See the resident’s account in JAMA which exemplifies the double bind of the psa test. Merenstein DJ. JAMA. 2004;291(1):15-16. “A Physician’s Experience With a Malpractice Lawsuit.”
I have this trade-off conversation with my male patients all the time. Once I lay out the pros/cons of PSA testing, many men decline it just like you did. Curious if you've ever read Pandora's Lab by Paul Offit, MD? In the Learning from the Past chapter, he quotes Richard Ablin, the discoverer of the PSA test: "As I've been trying to make clear for many years now, PSA testing can't detect prostate cancer and, more important, it can't distinguish between the two types of prostate cancer- the one that will kill you and the one that won't. I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster."
I keep wondering why the Sensible Medicine team is always considering all cause mortality. Unless you lump all cancers and all cardiovascular disease together, any particular cause of death is low. So after not smoking, taking a statin, wearing a seatbelt, it would seem valuable to lower each individual cause of mortality, if possible at a reasonable cost of money, time and anxiety. As a physician (radiologist) in his 80's, I never could quite understand the recommendation not to screen, and now I see that this study, combined with the newer information provided in the comments, I will definitely get screened at my next physical.
I have no issue with this position per se. However, my father developed a very aggressive form of prostate cancer in his early 70s. This is what caused his death roughly 6 years later even though he received prompt treatment that initially dropped his PSA to zero. Both of my grandfathers died of cancers before age 70.
I have an elevated PSA so I have it checked biannually because I would much prefer to catch a cancer early to determine if it is an aggressive form needing prompt treatment or active surveillance makes the most sense.
So, just to be clear, we are talking about populations and not individuals and these are populations judged to be average risk. The delta will vary greatly once we have individual risk factors taken into account. For patients at average risk, it is not for me to decide, it is for the patient to decide. My job is to provide information in a way that the patient can digest and make a decision. I usually use the USPSTF infographic on PSA testing. One might think it is biased but the data are remarkable similar to the data in the article in question. About 2 lives saved per thousand screening balancing against the adverse consequences of treatment. When I give them that information my estimate is that about 90% opt to not have the test. For those that do want the PSA I am happy to order it
As to the argument that treatment has gotten better and that should invalidate the study in question, I am reminded of the adage "When you are a hammer everything looks like a nail" If there is a new study about PSA testing using the latest treatment my mind is open but if the results are no better I would not be surprised if people state that treatment has advanced since then. We see this in many other fields in medicine.
In my own case: At the age of 60 (2015), I decided to stop getting PSA screenings. At the time I was the Medical Director for a TPA/PPO company in Seattle, and my reading of the relevant literature convinced me to forego more such screening. My PSA values had always been WNL and my prostate cancer risk was not elevated. But in 2016, when my PCP offered a PSA test, I decided (after some discussion) to have the test. The results were alarming - a significant elevation. I decided to ‘watchfully wait’. The next test was worse and a biopsy was performed. The results were positive for cancer, but were eligible for more waiting. A year later, the PSA was significantly elevated and another biopsy was performed. This found high risk cancer, and I elected laparoscopic (robotic) total prostatectomy. During the initial stage of this surgery I suffered from an accidental small bowel perforation requiring repair complicated by other factors. I was hospitalized for 21 days. After recovering from this episode, I went on to IMRT and ADT. Since finishing treatment, my PSA’s remain <1 and I consider myself cured.
So my current perspective on screening? I’m glad I chose that last screening. In spite of my unpleasant treatment experience, I am glad I am not suffering from Stage 4 prostate cancer as is my friend Larry…!
Mr. Mandrola might wish to consider the appropriateness of the study end point of all cause mortality. He should reconsider the impact of an undiagnosed, ultimately metastatic CaP and the impact on QALY. Over the past 40 years we have identified from the original Swedish Mens Prostate Study (Uppsala) that active surveillance is better than watchful waiting. We have also risk stratified the CaP based on PSA level and Gleason Score, now Gleason Group into low, high and favorable or unfavorable intermediate risk. These disease characteristics do make a difference in the natural history of progression of disease. We have over time changed our treatment recommendations and algorithms based on the Gleason Group. We no longer treat GS 5 and far fewer GS 6 cases because of precisely the fact that low risk prostate cancer is that: low risk. We follow with active surveillance. We definitely recommend treatment of high risk (GS 8,9,10) CaP as it does metastasize, can cause widespread boney mets which are painful, and eventually can cause death. This is or should be put into context of overall performance status and the reasons for that. We went through similar discussions with breast cancer screenings and the USPSTF opposition to mammogram screenings. The Health Insurance Plan of NY 1979 study demonstrated the effectiveness of breast cancer screening, but a screening study is just that: screening. It tells us whether we need to look further or not. Screening studies of the past have demonstrated they are well capable of identifying occult or previously undetected disease, starting with Paps of the early 20th century, and continuing with mammograms and PSA tests of the late 20th century. The decision to treat or not to treat is another question entirely and must be viewed in a very holistic manner taking into consideration many factors.
In breast cancer where these questions have been asked based on the same type of study cited here for prostate, the Early Breast Cancer Trialists Cooperative Group (Oxford) did an initial meta-analysis which demonstrated there was an advantage to treatment of early stage breast cancer, provided the life expectancy at diagnosis was about 8 years or longer. This finally put to rest the CALGB study that advocated initially ceasing screening at 65, then 70. It was driven home to me when I was asked if I could treat a centenarian with a locally aggressive skin cancer. My response, was, sure, but why? The ENT referring said, that's what I thought when the patient was 96. We did treat, the cancer was well controlled, and the patient died at age 108 with no evidence of skin cancer.
Life quality is a function of not just death from a disease process, but also a function of how will that process affect my remaining years and the things I can do with them if we treat it that I could not without treatment. Study authors: take note of your endpoint decisions.
I am personally biased. One of the advantage of being a physician is distinguishing sense from nonsense. At age 58, I had a backache and thought of my dad's uncle who died of prostate cancer in 1957. It came out his back in granulation like tissue... an infected mess which we could smell all over the house. My first PSA test was 3.83. That made me nervous. So I re-checked it four months later, with the result being 7.54. My boss said the same happened to him. I went to Mayo. I can tell you that you have NOT lived until you have a prostate biopsy at the Mayo. I had at least 12 biopsies from several sites and most showed high grade prostate cancer.
I chose my urologist well. I refused the one who said he would save the nerves one one side and found one who would save both sides with a robot. In 19 years I've had about 3 PSAs all zero. Everything works fine. I have never been able to pee better. I was out of work for two weeks. The radicle prostatectomy was less trouble that the biopsy, which was bad! I later thought about family history, and recognized that I had this coming from three sides of my family, most of whom died FROM prostate cancer in their 60's and 70's.
When I arrived in this community nine years ago, I found seven men with prostate cancer between the ages of 50 and 75. Half of them were dead from their prostate cancer within a year and four of them have been surviving after their external beam, but are presently on forever medication's. It is his last group about which I would like to write now. You said that the age of death is the same for those men who were diagnosed with prostate cancer by PSA and those in the control group. My point is that death is a relatively insensitive parakeet. In the death group are 4 sub groups. One group would be the ones who didn't have prostate cancer. Another group who had asymptomatic prostate cancer and another group who had symptomatic and partially treated prostate cancer, finally, those like me who have been successfully treated for prostate cancer, and who remain completely asymptomatic.
When people talk about the evils of PSA testing, they generally don't discuss the problems of delayed diagnoses or ongoing prostate cancer treatments. My personal bias is if I had to belong to the successfully treated group, as I do, or the unsuccessfully treated group, I would choose to belong to the successfully treated group. I had a very intelligent professor who used to say, 'hard diagnosis, easy treatment, or easy, diagnosis, and hard treatment." Most discussions about the evils of PSA testing, never actually raise the issue of easy diagnosis and hard treatment, in terms of money, pain or suffering.
I agree. I got a PSA at 9 about 5 years ago. Scary. Had told PCP not to include PSA in blood test, but he blamed the lab for doing it anyway. Yale University uro said do biopsy. I said no, wait, MRI please. He arrogantly poo-poo'd that, but I insisted. MRI said I had a very large prostate, which produces a lot of PSA. And a tiny equivocal lesion, which a top uro radiologist said not to worry about.
I would have gotten a transrectal (i.e., transfecal) biopsy, standard here. In Europe, transperineal is very common. Much lower chance of sepsis. Much lower use of antibiotic prophylaxis, a good thing in my view. It would have been hard to find anyone to do a transperineal. A UW uro told me his department didn't want to spend its limited money going over to it. Antibiotics kept sepsis rate very low.
There are better tests in combo with PSA for biomarkers and genetics. Knowing that I'm continuing to watch my PSA levels. Not sure how easy it is to get that testing and if insurance will pay.
This is such an ignorant argument. Sure, PSA in isolation is not a great test, but if you're only checking PSA, you're not practicing modern medicine (even if you are practicing guideline medicine). Layer PSA, PSA velocity, PSA density, free PSA, four-kallikrein (4K) score, and a multi-parametric MRI and you have a very high sensitivity and specificity for diagnosing prostate cancer.
If you're trying to diagnose an MI, would you get a single troponin and no other tests? No. So why is this is culture with prostate cancer screening?
There is no ignorance here. The increasingly available tests and scans for diagnosing prostate cancer add to cost and morbidity for the patient but do not change the fact that the mortality benefit is minimal. Most men will die from something else, very commonly the MI that you mentioned. That is the reason that heart disease is evaluated more thoroughly and carefully because it has a substantial, real, and proven benefit.
When a resident in Family Practice in the early 90's, this exact issue was on the table. Even with the limited data from those times, the debate was nearly identical. A urologist noted that the PSA test was his job security. --He knew he'd get a ton of procedures from the PSA test, though he couldn't honestly state it actually helped patients live longer. I was highly skeptical, and remain so to this day.
Here's my imaginary consultation: The PSA screening test will detect a small percentage of cancers compared to testing only for symptoms. The test cannot distinguish slow v fast growing cancer. Most positive tests will detect an incidental/indolent cancer, not requiring treatment. However, it is likely you'll need lots of tests and procedures to determine the difference. These procedures entail risk. For many men, a positive test will generate long-term worry without conferring any benefit, and even the chance of harm.
The test will not add to your life expectancy. This is because the harms of the test cancel any benefit from early detection. Given that you have no risk factors other than age, I advise against getting the test. Were there risk factors such as "My father died from prostate Ca atb age 60 and my brother was recently diagnosed.", I'd discuss further, and almost certainly order the test.
The odds of a PSA test preventing a prostate cancer death is lower than the odds of developing macular degeneration before age 55 which makes it seem like a waste of time. Nevertheless, at age 68 my wife insisted that I get a PSA test at my upcoming physical. The number was very high and a biopsy revealed a cancer with a Gleason rating of 8. Additional testing demonstrated that the cancer had not yet spread anywhere and so I believe the PSA test extended my life expectancy and the quality of my remaining life significantly. It is seven years now and I am still cancer free. Am I the one in 500?
An infographic for this issue: https://researchtranslation.substack.com/p/psa-screening-for-prostate-cancer
No psa for me. Have seen too many complications from prostate biopsies and prostate cancer surgery in patients and friends. Should have said I wish there was no psa for me LOL - my doctor still orders it and I understand. Tasking the pcp with having a discussion with patients on such a nuanced topic is ridiculous in my opinion. Many pcps will conclude that doing the test and having the urologist discuss the options with the patient if it is elevated is the only sane approach. At least until the PSA is taken off the screening menu. see Merenstein case (Virginia, ~2003–2004). A resident discussed PSA pros/cons with a patient and did not order the test. A jury did not find the physician negligent, but the residency program was reportedly hit with about a $1 million verdict. See the resident’s account in JAMA which exemplifies the double bind of the psa test. Merenstein DJ. JAMA. 2004;291(1):15-16. “A Physician’s Experience With a Malpractice Lawsuit.”
every patient is an n of 1. most likely they're in the meat of the distribution, but they might be in the tails.
I have this trade-off conversation with my male patients all the time. Once I lay out the pros/cons of PSA testing, many men decline it just like you did. Curious if you've ever read Pandora's Lab by Paul Offit, MD? In the Learning from the Past chapter, he quotes Richard Ablin, the discoverer of the PSA test: "As I've been trying to make clear for many years now, PSA testing can't detect prostate cancer and, more important, it can't distinguish between the two types of prostate cancer- the one that will kill you and the one that won't. I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster."
Hard to argue with that!
Check PSA-Risk
No Check PSA-Risk
Hmmm
I keep wondering why the Sensible Medicine team is always considering all cause mortality. Unless you lump all cancers and all cardiovascular disease together, any particular cause of death is low. So after not smoking, taking a statin, wearing a seatbelt, it would seem valuable to lower each individual cause of mortality, if possible at a reasonable cost of money, time and anxiety. As a physician (radiologist) in his 80's, I never could quite understand the recommendation not to screen, and now I see that this study, combined with the newer information provided in the comments, I will definitely get screened at my next physical.
I have no issue with this position per se. However, my father developed a very aggressive form of prostate cancer in his early 70s. This is what caused his death roughly 6 years later even though he received prompt treatment that initially dropped his PSA to zero. Both of my grandfathers died of cancers before age 70.
I have an elevated PSA so I have it checked biannually because I would much prefer to catch a cancer early to determine if it is an aggressive form needing prompt treatment or active surveillance makes the most sense.
There’s a reason why the PSA is promoted in a public service announcement (a PSA PSA) by Depends! It’s good for them, bad for you.
So, just to be clear, we are talking about populations and not individuals and these are populations judged to be average risk. The delta will vary greatly once we have individual risk factors taken into account. For patients at average risk, it is not for me to decide, it is for the patient to decide. My job is to provide information in a way that the patient can digest and make a decision. I usually use the USPSTF infographic on PSA testing. One might think it is biased but the data are remarkable similar to the data in the article in question. About 2 lives saved per thousand screening balancing against the adverse consequences of treatment. When I give them that information my estimate is that about 90% opt to not have the test. For those that do want the PSA I am happy to order it
As to the argument that treatment has gotten better and that should invalidate the study in question, I am reminded of the adage "When you are a hammer everything looks like a nail" If there is a new study about PSA testing using the latest treatment my mind is open but if the results are no better I would not be surprised if people state that treatment has advanced since then. We see this in many other fields in medicine.
In my own case: At the age of 60 (2015), I decided to stop getting PSA screenings. At the time I was the Medical Director for a TPA/PPO company in Seattle, and my reading of the relevant literature convinced me to forego more such screening. My PSA values had always been WNL and my prostate cancer risk was not elevated. But in 2016, when my PCP offered a PSA test, I decided (after some discussion) to have the test. The results were alarming - a significant elevation. I decided to ‘watchfully wait’. The next test was worse and a biopsy was performed. The results were positive for cancer, but were eligible for more waiting. A year later, the PSA was significantly elevated and another biopsy was performed. This found high risk cancer, and I elected laparoscopic (robotic) total prostatectomy. During the initial stage of this surgery I suffered from an accidental small bowel perforation requiring repair complicated by other factors. I was hospitalized for 21 days. After recovering from this episode, I went on to IMRT and ADT. Since finishing treatment, my PSA’s remain <1 and I consider myself cured.
So my current perspective on screening? I’m glad I chose that last screening. In spite of my unpleasant treatment experience, I am glad I am not suffering from Stage 4 prostate cancer as is my friend Larry…!
Mr. Mandrola might wish to consider the appropriateness of the study end point of all cause mortality. He should reconsider the impact of an undiagnosed, ultimately metastatic CaP and the impact on QALY. Over the past 40 years we have identified from the original Swedish Mens Prostate Study (Uppsala) that active surveillance is better than watchful waiting. We have also risk stratified the CaP based on PSA level and Gleason Score, now Gleason Group into low, high and favorable or unfavorable intermediate risk. These disease characteristics do make a difference in the natural history of progression of disease. We have over time changed our treatment recommendations and algorithms based on the Gleason Group. We no longer treat GS 5 and far fewer GS 6 cases because of precisely the fact that low risk prostate cancer is that: low risk. We follow with active surveillance. We definitely recommend treatment of high risk (GS 8,9,10) CaP as it does metastasize, can cause widespread boney mets which are painful, and eventually can cause death. This is or should be put into context of overall performance status and the reasons for that. We went through similar discussions with breast cancer screenings and the USPSTF opposition to mammogram screenings. The Health Insurance Plan of NY 1979 study demonstrated the effectiveness of breast cancer screening, but a screening study is just that: screening. It tells us whether we need to look further or not. Screening studies of the past have demonstrated they are well capable of identifying occult or previously undetected disease, starting with Paps of the early 20th century, and continuing with mammograms and PSA tests of the late 20th century. The decision to treat or not to treat is another question entirely and must be viewed in a very holistic manner taking into consideration many factors.
In breast cancer where these questions have been asked based on the same type of study cited here for prostate, the Early Breast Cancer Trialists Cooperative Group (Oxford) did an initial meta-analysis which demonstrated there was an advantage to treatment of early stage breast cancer, provided the life expectancy at diagnosis was about 8 years or longer. This finally put to rest the CALGB study that advocated initially ceasing screening at 65, then 70. It was driven home to me when I was asked if I could treat a centenarian with a locally aggressive skin cancer. My response, was, sure, but why? The ENT referring said, that's what I thought when the patient was 96. We did treat, the cancer was well controlled, and the patient died at age 108 with no evidence of skin cancer.
Life quality is a function of not just death from a disease process, but also a function of how will that process affect my remaining years and the things I can do with them if we treat it that I could not without treatment. Study authors: take note of your endpoint decisions.
Disclosure: I am a radiation oncologist.
I am personally biased. One of the advantage of being a physician is distinguishing sense from nonsense. At age 58, I had a backache and thought of my dad's uncle who died of prostate cancer in 1957. It came out his back in granulation like tissue... an infected mess which we could smell all over the house. My first PSA test was 3.83. That made me nervous. So I re-checked it four months later, with the result being 7.54. My boss said the same happened to him. I went to Mayo. I can tell you that you have NOT lived until you have a prostate biopsy at the Mayo. I had at least 12 biopsies from several sites and most showed high grade prostate cancer.
I chose my urologist well. I refused the one who said he would save the nerves one one side and found one who would save both sides with a robot. In 19 years I've had about 3 PSAs all zero. Everything works fine. I have never been able to pee better. I was out of work for two weeks. The radicle prostatectomy was less trouble that the biopsy, which was bad! I later thought about family history, and recognized that I had this coming from three sides of my family, most of whom died FROM prostate cancer in their 60's and 70's.
When I arrived in this community nine years ago, I found seven men with prostate cancer between the ages of 50 and 75. Half of them were dead from their prostate cancer within a year and four of them have been surviving after their external beam, but are presently on forever medication's. It is his last group about which I would like to write now. You said that the age of death is the same for those men who were diagnosed with prostate cancer by PSA and those in the control group. My point is that death is a relatively insensitive parakeet. In the death group are 4 sub groups. One group would be the ones who didn't have prostate cancer. Another group who had asymptomatic prostate cancer and another group who had symptomatic and partially treated prostate cancer, finally, those like me who have been successfully treated for prostate cancer, and who remain completely asymptomatic.
When people talk about the evils of PSA testing, they generally don't discuss the problems of delayed diagnoses or ongoing prostate cancer treatments. My personal bias is if I had to belong to the successfully treated group, as I do, or the unsuccessfully treated group, I would choose to belong to the successfully treated group. I had a very intelligent professor who used to say, 'hard diagnosis, easy treatment, or easy, diagnosis, and hard treatment." Most discussions about the evils of PSA testing, never actually raise the issue of easy diagnosis and hard treatment, in terms of money, pain or suffering.
Thank you for showing that being a doctor doesn’t keep you from making bad choices.
I agree. I got a PSA at 9 about 5 years ago. Scary. Had told PCP not to include PSA in blood test, but he blamed the lab for doing it anyway. Yale University uro said do biopsy. I said no, wait, MRI please. He arrogantly poo-poo'd that, but I insisted. MRI said I had a very large prostate, which produces a lot of PSA. And a tiny equivocal lesion, which a top uro radiologist said not to worry about.
I would have gotten a transrectal (i.e., transfecal) biopsy, standard here. In Europe, transperineal is very common. Much lower chance of sepsis. Much lower use of antibiotic prophylaxis, a good thing in my view. It would have been hard to find anyone to do a transperineal. A UW uro told me his department didn't want to spend its limited money going over to it. Antibiotics kept sepsis rate very low.
There are better tests in combo with PSA for biomarkers and genetics. Knowing that I'm continuing to watch my PSA levels. Not sure how easy it is to get that testing and if insurance will pay.
This is such an ignorant argument. Sure, PSA in isolation is not a great test, but if you're only checking PSA, you're not practicing modern medicine (even if you are practicing guideline medicine). Layer PSA, PSA velocity, PSA density, free PSA, four-kallikrein (4K) score, and a multi-parametric MRI and you have a very high sensitivity and specificity for diagnosing prostate cancer.
If you're trying to diagnose an MI, would you get a single troponin and no other tests? No. So why is this is culture with prostate cancer screening?
There is no ignorance here. The increasingly available tests and scans for diagnosing prostate cancer add to cost and morbidity for the patient but do not change the fact that the mortality benefit is minimal. Most men will die from something else, very commonly the MI that you mentioned. That is the reason that heart disease is evaluated more thoroughly and carefully because it has a substantial, real, and proven benefit.
When a resident in Family Practice in the early 90's, this exact issue was on the table. Even with the limited data from those times, the debate was nearly identical. A urologist noted that the PSA test was his job security. --He knew he'd get a ton of procedures from the PSA test, though he couldn't honestly state it actually helped patients live longer. I was highly skeptical, and remain so to this day.
Here's my imaginary consultation: The PSA screening test will detect a small percentage of cancers compared to testing only for symptoms. The test cannot distinguish slow v fast growing cancer. Most positive tests will detect an incidental/indolent cancer, not requiring treatment. However, it is likely you'll need lots of tests and procedures to determine the difference. These procedures entail risk. For many men, a positive test will generate long-term worry without conferring any benefit, and even the chance of harm.
The test will not add to your life expectancy. This is because the harms of the test cancel any benefit from early detection. Given that you have no risk factors other than age, I advise against getting the test. Were there risk factors such as "My father died from prostate Ca atb age 60 and my brother was recently diagnosed.", I'd discuss further, and almost certainly order the test.
Full disclosure: I've never had a PSA test.
The odds of a PSA test preventing a prostate cancer death is lower than the odds of developing macular degeneration before age 55 which makes it seem like a waste of time. Nevertheless, at age 68 my wife insisted that I get a PSA test at my upcoming physical. The number was very high and a biopsy revealed a cancer with a Gleason rating of 8. Additional testing demonstrated that the cancer had not yet spread anywhere and so I believe the PSA test extended my life expectancy and the quality of my remaining life significantly. It is seven years now and I am still cancer free. Am I the one in 500?