More Evidence Favoring PSA Screening

Question for Casey:

Do they know what percentage of intermediate-risk cases will progress to death if left untreated? That would be a useful number to know. You called it a "small percent of a minority percent." And does that include all treatment, or just treatment upon initial diagnosis? Actually, it would great to have that number for all three stages of risk.

One more question: If it's really true that only 1 in 48 treated men has extended his life by doing so, why don't they just come out against all treatment, period? Is that really what they're heading toward, with the protocols against PSA screening representing the less shocking first thrust toward that end?

I guess what a lot of us are having a hard time with is the seeming contradiction between the widespread mortality from PC and the apparently non-aggressive nature of the vast majority of variants of the disease. Unless you are one of the very unlucky ones with the rare deadly variant, it seems, you can pretty much ignore your diagnosis and forgo treatment altogether with no effect on your life expectancy. It's differentiating between the two situations that seems to be the real problem. Hopefully, they will come up with a test soon to distinguish between them.

There are Gleason 7 cases, that can act very aggressive, despite the "7". Gleason 7's can also be very unpredictable in nature, treatment, and outcome. It's not so cut and dry as being indicated. My own case is a good example of that. It's never acted like a Gleason 7 from the beginning. I was diagnosed as a 4+3, and after surgery, it was 3+4. That should have been a good thing, but it hasn't acted that way.

Surgery was considered failed 9 months out. Then I got slammed with 72 gys. of IMRT radiation to the pelvic bed. Forget about the disaster part of it, regardless, the radiation didn't remotely slow the cancer down, it was declared failed in less than 9 months.

As of December, 2012, my PSA was at 40.x, and rising fast. So much for an intermediate cancer not being dangerous. My oncologist still believes mine is the result, and danger, of rapid PSA velocity in the year before diagnosis. In those cases, the prognosis for dying from PC directly can be as much as 10 fold, regardless of any treatments.

david

Jerry, any of us could be the 1 out of 48. I am for whatever it takes for that "1" guy to have whatever is needed to save his life.

david

David,

I hope we all are that "1" indeed.....

Hope you're doing good these days...

JL

We've sort of wandered away from the original subject of this thread which, as I dimly recall, had something to do with whether PSA screening is a good or a bad thing. Put me down as being in favor of allowing screening as young as 40 and maybe before.

At the same time I understand that the needless anxiety produced in low-volume Gleason 6 men can lead to over-treatment, either because doctors are too aggressive in suggesting it, or because the anxious patients demand it (depending on your point of view) and, to address that problem, I would be agreeable to the idea of changing Gleason 6 to a hyphenated cancer. In addition to my prostate cancer I have two other areas where biopsies have reported "pre-cancer" -- in my esophagus where I have Barrett's syndrome and in the skin of my arms where I have had pre-cancerous neoplasms reported on my blotchy bits. The "pre-" in "pre-cancer" is quite reassuring. I am quite comfortable monitoring those conditions and I understand that if they progress more aggressive treatments may be needed. I'd like to see Gleason 6 cancer re-designated a "proto-cancer" or something like that to make the distinction clearer when counseling patients about their pathology reports. It is still very much a concern and, if it appears in high volume it may warrant curative treatment, but that would help men diagnosed with low-risk cancer internalize their options.

My first PSA test was done only after I had been hospitalized for a prostate infection at the age of 54 and my newly-acquired urologist wondered what else might be going on with me. So I am not an example of a man picked up by screening. My first PSA test was done while I had a diagnosed, symptomatic case of prostatitis and my urologist did the follow up test to verify that it went back down (which it did but less than he expected).

As for men whose Gleason scores go down on subsequent "confirmation" biopsy, I don't think the score going down means that much. It's not likely that a biopsy needle will serendipitously excise ALL the cancer present so the sensible presumption is that it was simply missed the second time. I had repeated biopsies (four in all) and I was diagnosed as a Gleason 6(3+3) on my third biopsy. My fourth (confirmation) biopsy was negative. My only indication that there was anything worrisome about my results came from a second set of slides from my third biopsy that was examined by a different pathologist and was graded GS7(3+4) although he remarked that there was so little cancer present in the one positive core that he almost missed it. Both pathologists rated their two different slides from my only positive core ever as 3-4 percent of the sample. One called his slice Gleason 6, the other called his Gleason 7. It seems likely that if the second pathologist had looked at the same slide as the first one did that the Gleason 6 diagnosis would have stood. My PSA was never higher than 8 something. A bit high for my supposed small volume cancer but believable. I made my decision to seek surgery based on very little reason not to continue surveillance.

As it turns out I had a rather large Gleason 9(4+5) tumor and the rather-low PSA for the size of the tumor was probably due to the lower PSA given off by higher-grade tumors. I believe my cancer was mostly in the anterior apex where it is difficult to sample with a standard transrectal ultrasound guided biopsy.

So put me down as being for a fairly liberal use of PSA testing, even in fairly young men, since what you don't know can't save your life. You can also put me down as an extremely-conflicted vote for measures designed to reduce the anxiety for men diagnosed with low-risk cancer. The statistics are fairly compelling that they are being over treated. And yet... and yet... There is a strong possibility that irrational anxiety saved my life. So go figure.

peter,

I see your points, but have a lot of issues in re-naming a Gleason 6. It's still a genuine cancer, and that's assuming it's truly "only" a Gleason 6 upon diagnosis. Even here HW, been way too many men that were upgraded after surgery. Biopsies are still too hit and miss in my opinion.

david

something more along those lines could be considered reasonable, peter

Chuck, good point about the biopsies. It took 3 with me spread over a year and a bit to find my cancer. It was there all along, but the first two were 12 cores each, and simply missed each time. 3rd time was the charm, and drew 7 out of 7 positive.

david

Purgatory said...
Chuck, good point about the biopsies. It took 3 with me spread over a year and a bit to find my cancer. It was there all along, but the first two were 12 cores each, and simply missed each time. 3rd time was the charm, and drew 7 out of 7 positive.

david

Hi David,

Thanks. Yes, that's the thing about biopsies -- they only sample, I believe, about 1% of the prostate and it is very easy for the needle to happen to punch past a tumor or between tumors, etc. It is easy to receive a false negative.

I was very lucky to have a highly experienced urologist who found mine with one biopsy of 20 cores. The cancer was only 2% of the entire prostate. He initially said he would normally have recommended AS. But, with 3 cores out of the 20 being positive, he believed in what he termed "aggressive" treatment & recommended Mr DaVinci.

I would have never known about the cancer if it had not been for a spike in my PSA test in comparison to the previous one. It was the spike, not the actual numbers, that triggered the recommendation for the biopsy.

Thus, if not for the PSA test, I would still be walking around with PC and not even know it. I was lucky that the Gleason grade (both clinical & pathological) was 3+3. But I did have a positive margin. The tumor was organ confined, but right at the edge. While a 3+3 usually does not metastasize, I would have still had a more complicated case within a couple years.

Here's wishing you well,
Chuck

A Question For Casey:
You mentioned that we need to "Rally"..Well, I'm ready! I've written articles which were published in our local newspaper, counseled individuals, and have contacted the VA in Washington...What else can I or should I do to get the word out???Physicians are not offering psa tests to their patients since the main manta of their oath is "to do no harm"..the task force's stand is that there are "harms" by offering the test...
Until a new test is introduced or the "recommendation" is repealed as it was for the breast cancer recommendation, what can I do as a prostate cancer testing advocate?? Any advice will be appreciated!!
Bill

I was tested when I was 36, Biopsy results on my 37th birthday... Based on my pathology pre and post RRP I was not at an early stage of PC... So if I waited until 40 could have been much worse and spread outside the prostate.

Thank God I got tested to start a baseline which the baseline was high...:)

My question to my Uro is when does my son get tested 10 now, which I have some time I hope....

Casey:

The "Wake-Up Call" as interpreted by Consumer Report, among others, is to advise ALL MEN against getting a PSA test because the harm outweighs the good. This strongly-worded advice was included in their front page issue "Cancer Tests You Need--And Those To Avoid" of two months ago. Guess what test was on the list to avoid? Notice they didn't say to ask about, or look into, or to question--their advice was unequivocal: DON'T GET THIS TEST.

And while I have you here, you never answered my questions regarding your post from earlier in the thread:

Do they know what percentage of intermediate-risk cases will progress to death if left untreated? That would be a useful number to know. You called it a "small percent of a minority percent." And does that include all treatment, or just treatment upon initial diagnosis? Actually, it would great to have that number for all three stages of risk.

One more question: If it's really true that only 1 in 48 treated men has extended his life by doing so, why don't they just come out against all treatment, period? Is that really what they're heading toward, with the protocols against PSA screening representing the less shocking first thrust toward that end?

And what do you think the impact of that minor pullback in the heart of the text will be compared to the much more prominent placement of the PSA on their list of TESTS TO AVOID (because they do more harm than good.) That's more than enough for most men to justify bagging the test. And what about my questions?