I'm wondering when the little brown ribbons are coming out for prostate cancer awareness...

It depends, the PSA test, costs around $50 or so, screening companies love it, because they make money off it, insurers hate it, because it doesn't take many patients to end up a serious amount of money, and then premiums go up and those paying the premiums complain, because of the cost. Think of a company that has 10,000 employees of which half are male, that's 5,000 tests at a cost of $250,000 someone has to pay that....

The real question is, how many cases of prostate issues are found via the PSA that are not found through the physical exam.

It's too bad that we have not had an oncologist chime in...possibly I can get mine to register. I had no symptoms of prostate cancer but took the PSA test as part of physical. Tested PSA was 6.7 and was sent to a urologist who did a biopsy. Biopsy indicated cancer. Three doctors said that I had to do something about it. I did radiation treatments then radioactive seeds and was ready to ride a bike within a month. PSA fell no lower than 1.2 and after three years my PSA has started to climb. It means that when they killed the cancer in my prostate there was cancer s already out of the prostate. I believe that the PSA test and treatment also has given me another three years on top of the ten years my oncologist tells me I should have left.

I listened to a Doctor on NPR radio talk about the PSA testing controversy and he had some interesting statistics. I think he said that 7 of 1000 men who have the protate removed die from complications of the surgery. He said that even more patients die within 30-60 days from strokes and heart attacks that are somehow a result of the procedure. Statistics tell us that 40percent of men that have the procedure become impotent. Another 40-50 percent end up incontenent to some level. There is also a general tendency to rush to a judgement that something needs to be done to treat the cancer as soon as it is diagnosed. There are many other complications from prostate cancer treatment that aren't mentioned here. Although I can't write my name in the snow like I could when I was 20 years old I was fortunate enough to escape all these complications except for the big one...I still have cancer.

This new PSA testing controversy is a good thing because it is a reevaluation of what the medical community has been doing for us(and to us) for the last 10 years. No body has said that treatment hasn't saved lives. They are just questioning how many people they have made miserable in the process.

This is a question that everyone needs to answer with help from their doctor. Everyone needs to MAN UP here. This ain't about insurance companies , politics and money. Live your bucketlist everyday, treat people right and cherish the time you have left because soon we'll all be dead anyway.

As I understand it, the problem is not that detecting prostate cancer is difficult. The problem is distinguishing aggressive life-threatening prostate cancer from other prostate cancers. The statistic is that something like 50% of men have prostate cancer at the time of their death, but did not die because of prostate cancer.

There is an evaluation called the Gleason Scale that attempts to evaluate growth rate of the cancer cells, but there is a lot of science and medicine left to learn.

Sorry to use the jargon "herd level". That is common nomenclature when something affect the whole population. It isn't a matter of the outcome. It is a matter of the focus. Herd level vs. Individual.

The fact is that depending on one's personal financial status and health plan, or lack thereof, if a study convinces the policy makers to remove something from the approved list it becomes unavailable. Also, if a certain drug or test does not meet the manufacturer's profiit goals it becomes unavailable. Reduced use can bring that result.

To me the bottom line is that by and large tests are not to mechanically determine a course of action. They produce information for an intelligent analysis. It is that intelligent analysis and discussion between provider and patient that brings an acceptable course of action.
Too many, including some who have posted in this thread, appear to be unwilling to accept the ambiguity and the necessary patient participation that is today's reality.

I think the authors of this recent PSA data analysis and recommendation were guided by the medical ethic of "First, do no harm". Wise words.

There has been an excellent series of articles on this subject in the NY Times starting last week. I particularly liked this one:

http://www.nytimes.com/2011/10/09/ma...tml?ref=policy

Wise words but not what guided the authors. They were guided by the desire to determine on a population wide basis whether the test was economically and procedurally worthwhile. Such studies are actually pretty common. The uproar about mammography was the result of such a study. Whether we like it or not much of our medical care is determined by political and economic factors at corporate and governmental levels. Bottom line we are talking about money.

From what I know this study could just as well have recommended better analysis and interpretation of PSA data resulting in better post test actions. It certainly appears the damage comes not from the PSA test results but from ill considered actions from physicians and patients. Of course the providers make more money from those actions than from patient counseling so maybe that might be an area deserving more focus.

Added after intervening post while I was typing:

Since the NYTimes article is in line with my thoughts it is the absolutely best thing :) .

Excellent article. Confirmed my intent to just say no to the PSA test.

Isn't that the new recommendation? That only certain women with risk factors start early on the mammograms? And the rest start later than they do now if at all? At least with women, there's some radiation in the mammogram, so there's a potential harm due to the test. Not 50+, but thought I'd chime in as I've started getting my PSA at the checkup (I'm not good about going in yearly, but when I have gone in I've had to ask specifically for it a couple of times). With some relatives recently getting theirs out (and some great grands dying of what we think is prostate cancer in their 40's), my mom's been pushing me to get it measured regularly since I hit 30. Since, they're drawing blood for my cholesterol and triglycerides and everything anyway, what's the harm in one extra tube drawn? Now, yes I'm getting the finger pushed off as long as I can, but I've already been scoped down there once and it ain't the end of the world.

I'm hoping the research into prostate cancer will give us the equivalent of BRCA1 and BRCA2 alleles that are indicators of increased breast cancer risk so that only those with heightened risk for prostate cancer (like my family history of it) will have to get tested more frequently and younger. I think it was my human physiology professor (or maybe it was anatomy) that said it was something like 80-90% of men over the age of 75 have at the very least an englarged prostate, but at that point in their lives the treatment was more likely to kill them than the cancer.

I know there will always be two opinions on a subject like this but as person that has had ProstateCancer- Can any of you "Doubters"- tell me of any other simple test that will indicate that there is a possibility that you "May" have P Ca.

I can't.

I know a high PSA count is not definitive of P Ca and I have work mate that has a PSA count of 27 and has been at that level for at least 15 years and Biopsy's show nothing. The DRE on me at the doctors indicated a problem- PSA count of 16 showed something amiss- Biopsy showed Cancer. I was lucky.

There is no other simple test. From the articles it sounds like other than PSA you go with a biopsy based on clinical symptoms. If I was in himespau's situation I would probably elect to have the test. Prostate cancer runs in the family, hits early, and kills so his cancer is much more likely to be disastrous than the average Joe's. For the average Joe the calculation is more difficult. Even a positive biopsy may not call for treatment. Once we get into our 70s the treatment is likely more dangerous than the disease.

My last post on this subject. I have to agree that after a certain age, screening on a regular basis is not necessary as you will most likely die from causes other than prostate cancer. The thing that I am seeing a lot of people miss here is that PSA, in itself, is not an indicator of prostate cancer, but you need to have some base line results to start with. Elevated PSA can be present with several conditions. It's the PSA Velocity that is a red flag for considering prostate biopsy and not just an elevated PSA. However, in order to know what the PSA Velocity is, you must have more than one PSA test at least one year apart.

If you wait until you have symptoms, you already have the cancer and the amount and type of treatment will be determined by the Gleason Score which is determined by the biopsy. I have been through this and I wished that they had found the cancer when my Gleason Score was low and I could have gotten away with just having the brachytherapy. Had I waited or not had another PSA test done to see what my PSA Velocity was, the cancer would have broken through the prostate wall and gone into the surrounding tissue, bone marrow and/or lymph nodes. If this is about cost effectiveness, see what it costs if the cancer gets into the bone or lymph nodes and see how much your life span changes.

I'm sorry if you guys that think that screening is not necessary until you get symptoms because it's a pain in the ass to go get screened. But if you are in your 50's or 60's, I think you would be singing a different tune if you get prostate cancer that has a high Gleason Score and then you have to go through all sorts of crap when you could have nipped it in the bud had you found out earlier. As someone previously mentioned, the bottom line is money and I pay my money to the insurance company to cover preventive tests.

I for one an not opposed to the test because it is a PITA. I'm sorry you had to experience this but, if the recommendation is accurate, you are simply wrong. Having the test will not make it more likley that you will get better results. It will make it more likely that you will get treatment you don't need. I will talk to my doctor about Gleason scores but from what I have been reading it is not possible to identify which tumors are aggressive at an early stage. If testing and diagnosis can (with reasonable accuracy) make such identifications (i.e. if patients can rationally decide when to treat and when to ignore) then the recommendations would be criminal.

Edit: when I talked about this to my doctor a year ago he recommended sticking with the test and I did. I will go over these issues again this year. If he starts recommending ignoring the absolute value of the test and only biopsying upon a showing of rapid increase and if he can document that that finding is fairly accurate for showing tumors I might consider continuing with the test. This would be on the theory that I would treat any tumor discovered. Based on current medical capabilities I would be more likely to back off in a few years (after 70) since I would be less and less inclined to treat.

One of the problems with prostate cancer is that is generally asymptomatic. By the time symptoms develop, it can be too late for treatment.

What kind of symptoms do non-testers think they will get before the cancer has progressed beyond normal treatment?

I had a very aggressive cancer with a lot of peripheral damage, yet no symptoms at all. In fact, my cancer returned aggressively 6 years later, again with no symptoms.

Who wants to risk no testing until they ejaculate blood or have no ejaculate at all? Or, even worse, starts having back or hip pain through metastases? If that happens, your treatment has gone way beyond normal prostate cancer treatment.

I've been told this is one of the side effects of Flomax. Which if we believe the ads significant numbers of men are using.


I guess whether to have a lab test and then have to make analysis and decisions following the test; or just do nothing and take what comes when symptoms arise depends a lot on an individual's personality. Some have a greater degree of self-discipline than others and so can make a decision and live with it. Others don't. Some providers are more willing to spend the time explaining and counseling their patients and other's aren't. Right now the system puts a premium on after test decision making; which evidence shows has not been up to par in all cases. But, if the test is not available neither patient nor doctor gets to make any decisions; until the disease manifests itself in other ways.

Do you realize that you are saying that you would be willing to go through 100 unnecessary prostate biopsies?
You would be willing to have that done 100 times, risking the complications of infection, etc?

Just doing a little reading, there is a new test in the study stage that detects Engrailed-2 a protein found in the urine if men with prostate cancer, if they can work this into a commercial product, you go to the pharmacy, buy the kit, take it to your doctors office, open it up and pee on the stick, and then your doctor looks at it, and tells you your prostate in cancerous, then do the biopsy. One of the issues with PSA is that if there are false positives, there is also the possibility of a false negative, which could have much more dire consequences.

I hope they come up with new tests but I don't like the concept of buying a kit and taking it to the doctors office. I would rather pee on the stick myself and see what color it turns. Then I can can go see the doctor if it turns red. :)

He'd probably make you pee on the stick again (or pee in a cup that's taken to the lab) to confirm the results, but I like this idea. Though it seems to me engrailed is one of those genes first discovered in a fruit fly that I had to read about way back when about and that gives me bad memories of trying to study fruit flies.

@donheff

You're talking a great deal of sense in this thread. Screening is only useful if the benefits outweigh the risks and if it leads to interventions that actually save lives.

Those who are in favour of routine PSA should ask themselves what their view would be if it had not yet been introduced to the general population but had been the subject of an extended clinical trial, with the outcome reported in the study. That outcome would have been something like this:

"PSA testing does detect prostate cancers. However, those whose cancers were detected by the test had outcomes that were very little different from those in the control group, who were not given the tests. In other words, having the test made no difference to their chances of getting cancer and virtually no difference to their chance of dying of it. In addition, the PSA test gave rise to many false positives which led many patients to receive invasive, risky and sometimes very damaging treatment they did not need."

In the light of such a trial, I suggest that very few people would want to introduce routine PSA testing or subject themselves to it. And an extended clinical trial, with pretty much exactly those results, is what you have been conducting in the States for years.

Well that would be another option, one blue line your fine, two blue lines, call you doctor, the doctor may just give you a referral to a Urologist and not even bother seeing you....

A few comments based on my experience;

Know your family history, PC does run in families.
Consider your age and general health with respect to any actions taken as a result of a high PSA score.
Pay attention to anything that could be symptomatic.
PSA is best looked at as a datapoint needing further investigation.

In November of last year I had routine bloodwork done. My GP suggested a PSA since I hadn't done it in years.
It came back a bit high (5.7) so he suggested we wait a few weeks, that I stay off the bike, and we'd repeat with a look at both total and free PSA. I of course had no symptoms.
The test came back with the same total count but the ratio of free to bound PSA was in a range only encountered when cancer is present. That convinced him to send me to a Urologist for further consultation.
The Urologist did a DRE and simply told me I needed a biopsy and explained why. The biopsy returned with positive results, 8 out of 12 cores cancerous, Gleason 7+.
The day after the biopsy I was in the hospital with septicemia from the biopsy, a nice fever racked 4 day visit. So no, you don't a casual meeting with a biopsy needle.
A few weeks later, back to the Urologist for a "what now" chat. He explained the situation, the possible treatments and the possible outcomes.
I told him I'd take 3 months to visit and consult with a radiation Oncologist, a DaVinci surgeon, witch doctors, the whole bit. I'd read up on treatments (or lack thereof) and be back in three months for yet another PSA. If it had gone up, I'd pick a course of treatment and go.
The 3 months lapsed, we did a third PSA with the obvious result, higher of course with velocity increasing. I elected DaVinci robotic surgery after even the Radiation Oncologist told me to consider nothing else. The reasoning being, at my age (59) and general condition (rail thin, 1000 mi./month cyclist) I'd recover from the surgery quickly, and the likelyhood of getting all the cancer was very high.
I had the surgery with the pathology report showing no evidence the cancer had spread beyond the prostate. My surgeon was smiling when he told me that, it really made my day.
I recovered quickly (walking the next morning, back on the bike in 5 weeks) and now have a 0 PSA score and here's hoping it stays there.

Here's the bit about family history, a week after the surgery my uncle (mom's bro) called having just heard from my mother about my little adventure.
He said, he'd had the same operation a few years earlier, and that his brother (another uncle) has PC and my grandfather had it when he died.
So moral of the story? PSA testing in my case raised a flag and paying attention to that flag did add years to my life, Gleason 7 is aggressive. I'm glad I paid attention to it, I'm glad my GP suggested it.

I'm tending to agree with Goldfinch, at least partially. Patients should be counseled on the risks of false positives. Today, any stay in a hospital or rehab center carries some risk of MRSA, among other things. Watchful waiting may be a pain in the neck and unsatisfying, but as someone who saw my dad die both of the complications of a less-than-necessary surgery (successful otherwise) combined with MRSA, I think even great hospitals are not reliable enough to trust with excessive treatments.

But I wouldn't want to eliminate PSA screens for younger folks, like me. If it's like with colonoscopies, docs would like to be able to compare risk assessment procedures (such as at my 58 yo) with "good" test results taken on the same patient when at a younger age. That means at least one young-age PSA test per male when in his 30's or so.

I don't want some faceless committee or agency cube dweller making a decision that my physician and I should make. Stay out of my business. I've already had skin cancer, so my risk profile is a little higher. This crap needs to stop. Next thing you know, some cube dweller will want to regulate how much lube I put on my bike chains.

Is that what is being proposed? I didn't think anyone was suggesting that you should be prevented from choosing to have a PSA test where that is appropriate, merely that routine PSA screening of everybody wasn't effective. And on the evidence, that seems to be right.

No one will stop you from doing whatever you want but health insurance should only cover useful medicine. I don't want my health insurance jacked up because you want homeopathy covered despite zero evidence of effectiveness. If you want homeopathy, pay for it. I suspect the same may happen with routine PSA tests. You can still pay for it. Based on what I am hearing here I suspect that PSA tests will probably remained covered in higher risk situations where reasons exist to suspect cancer and doctors want to monitor PSA velocity among other symptoms. Regardless, you could still elect to pursue it at your own cost.

The only thing that any committee or agency can decide is who gets to pay for the test, you or your insurer. If it's your insurer, then it means increased premiums for you or your employer, if your employer is government, then everyone gets to pay for it, with increased taxes or your great-grandchildren get to pay for it, in the future. If your employer isn't government then people who buy it's products or services get to pay for it. If you get to pay for it. then it's money that's out of your pocket, money that could have been used for something else.

The whole issue is that the test costs around $45, or at least it does here in Canada, is the benefit worth spending $45 or isn't it. For some people it is, for some it isn't. Interesting that in the US a positive PSA means a biopsy right away, you would think an Ultrasound scan would be done first, to see what the prostate looks like, maybe take some measurements, rather then scheduling an invasive procedure right away.