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Forbes article: Guys: You Don't Want That PSA Test For Prostate Cancer

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Posted 4/4/2017 2:37 AM (GMT 0)
Redwing, I've thought of money saved by the death of retired men too. I've also thought about the money made by the researchers and pharmas. If PCa is caught early, it's usually curable-- no expensive drugs.

The analyses of the PSA screening debate that I've read focus on things like infections caused by biopsy and unnecessary surgery for indolent cancer. But they never mention the plight of the man (and his wife) who gets a later stage diagnosis because he wasn't screened. Is living on hormones fun? My husband said he's gladly have 100 biopsies (with infections occurring for each) and 100 unnecessary surgeries if he could trade his diagnosis (local spread due to no PSA screening).

And what about the manner of death? I dare anyone who writes articles against screening to witness death from PCa in the bones.

I'm sure some men who prefer to stick their heads in the sand and that's their prerogative. Men should have a choice. The hardest part of this for me, by far, is knowing that it was likely preventable and if we had a different family doctor, it would have been.
Posted 4/4/2017 2:56 AM (GMT 0)
I am certainly glad I didn't read the article before my PSA test. And I am eternally grateful that my Uro insisted I start PSA testing at age 50. I hazard to think what my situation would be like today if I hadn't heeded his advice for a yearly PSA test.
Posted 4/4/2017 12:26 PM (GMT 0)
I think the article was written by a typical statistician. He found correlation, then assumed cause and effect. More screening, like PSA testing, does NOT drive over-treatment. Over-zealous doctors and under-educated patients cause over-treatment.

I'll stop here, as the remainder of my thoughts would be considered flaming, and might unnecessarily upset some patients. My point should be clear. I am in favor of screening, but also much in favor of patient education so that we can take responsibility for our own care choices.
Posted 4/4/2017 1:18 PM (GMT 0)
^^ Exactly ^^

All of my PCa brothers here have 'benefited' from PSA tests (and DRE, etc.) so we are the wrong target audience for that kind of article. When my PSA climbed a bit over 4, cancer cells had already spread to a node. PSA test + DRE = action required.
Posted 4/4/2017 1:45 PM (GMT 0)
Thanks Pratoman!! Too often the G8 and above are ignored (well G7 and above, me I'm G9).

I would like to take exception to the notion that few men die of PCa.

PCa is looked down upon simply because of two things
1) All the G6s that can be just monitored for progress and don't necessarily need treatment bring the rate down.
2) Mortality rate is based on 5 year survival.

Well, PCa kills more men EVERY darn year than any other cancer except lung cancer. If they would just remove the time factor and just use the the fact of how many die each year from this disease.

If we also remove G6s from consideration as they hardly ever go metastatic (half of all cases), plus remove the time factor.
PCa mortality rate suddenly becomes 23.5%. There are quicker more aggresive cancers, but this one still kills nearly one in four non-G6 men.
28K deaths divided by Half of 238K (taking out G6s) = 119K
Posted 4/4/2017 1:52 PM (GMT 0)
Hi All,

Please go to that link at the beginning of this thread if you have time and motivation (I know you have the later) and post a comment. I've been waging a personal war over there with the idiots that say PSA screening is detrimental to society.

Thank you,
Tim
Posted 4/4/2017 2:10 PM (GMT 0)
I am someone who's advanced cancer was found in my late 50's through PSA and digital tests (even though I was getting tested since I was 40). It is almost with intense hatred my feelings for who state "only a few are helped with testing". Let's be honest, one of the big the drivers for less testing is money. They are also singing the same song for breast cancer.

Even the data does not back them up. At PSA testing has gone down the percentage of advanced cancers has gone up.
Posted 4/4/2017 2:28 PM (GMT 0)
This (from the article, for those of you who failed to actually read it) is common sense:

American Academy of Family Physicians said...

There is convincing evidence that PSA-based screening leads to substantial over-diagnosis of prostate tumors. Many tumors will not harm patients, while the risks of treatment are significant. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients.

Who's "fault" is today's situation? The responsibility is, as this common sense position statement clarifies, "shared."

Sadly, some (not all) men can't see thru the haze and panic of "you have cancer," and they fail to get a basic handle on the disease. Evidence:

Somebody said...
... if I didn't have PSA screening starting age 50, I would be metastatic by now, if not almost dead. So for that reason, i\among others, I think the author is an idiot.

More evidence:

Somebody said...
overtreatment, smovertreatment

This is exactly why we have "idiot lights," as we have on cars, which is what I've heard the USPSTF position described as. A few idiots are making it worse for everyone else. It's a sad insult to both those with serious disease and those who invest time and energy to educate themselves.

Post Edited (JackH) : 4/4/2017 8:36:56 AM (GMT-6)

Posted 4/4/2017 3:06 PM (GMT 0)
JackH, that's a little harsh.

One quibble, this statement in the 1st section quoted as common sense uses a word that I think is at the core of the confusion/argument: "There is convincing evidence that PSA-based screening leads to substantial over-diagnosis of prostate tumors".

I don't think there is over-diagnosis. That would really require false-positive readings of biopsy cores to truly "over-diagnose prostate tumors". In screening, PSA is only, ever, and always, an indicator for biopsy or disease status; PSA is never diagnostic for tumors. One could argue it sends too many for biopsies, with a high rate of negatives. But a false positive biopsy would be the only way I see as "over-diagnosis".

On the other hand, over-treatment is a definite possibility, and is what we really have to work on.

Screen, diagnose any that are out there. But then, we must find a way to only treat those who will actually benefit. Not to keep urologists and hospitals with $2 million DaVinci robots busy generating profit. Not to keep radiation suites with $5 million radiotherapy machines busy generating profit. Not to keep brachytherapists with $2 million installed suites busy, generating profit. This is America, we do have a capitalist system, and profit is important. However, it shouldn't be allowed to drive treatment decisions, consciously or unconsciously.

We really need something better than PSA and Gleason score alone. Maybe genomic testing from the biopsy cores can be more revealing. Some way to ID people whose lives simply will never be threatened by the particular cancer they have. Some way to predict, and monitor, those whose cases might become threatening.

People hearing that they have cancer are suddenly exquisitely vulnerable to doctors. Education is key. How do we help people understand the wide range of disease that the simple phrase "prostate cancer" actually entails? How do we help a G6 with 5% of one core to make a balanced decision about coping with that? Those that were actually "overtreated" are unlikely to be, as you said, "idiots". Most of us however are ignorant of many fields, and trusting an apparently knowledgeable expert for guidance is not being an idiot.
Posted 4/4/2017 4:26 PM (GMT 0)
Then, along comes a guy like me. 63 years old. My regular doctor became concerned when my PSA went from 2.5 up to 5.6, and sent me to see a urologist. They measured my bladder content, and found it very full for a guy that just peed when I arrived at his office, and then, peed again when they asked if I could do a urine sample. Urologist said he waned to do a biopsy, and would do a digital just before that, so scheduled. He did the digital and said, yep, it.s feeling like an enlarged cancerous prostate. Took 12 samples and the lab found cancer in every one. The scheduled me for an MRI and bone scan, which was done. Bone scan showed good. MRI, however showed a prostate way enlarged and encroaching into my bladder (have had to use a catheter since the biopsy). He said no way it could be removed or either type of radiation. That left hormone treatments, and they started me on two weeks of a pill, and had the first Lupron shot after taking half the pills. Scheduled for a second MRI on June 2nd to see if the prostate is shrinking. Lupron has side effects. He told me to eat healthy, noting with processed added sugar, stay away from white bread, etc. No smoothies. Eating fruit is fine, but a smoothie, instead of consuming the sugar of, say an orange, you are combining maybe 6 oranges, and that's too much sugar. One side effect of Lupron is weight gain. I'm eating less and healthier and am losing weight.

My story shows that, if they had done only an annual digital exam, they would have found the cancer years ago I bet. PSA testing let it get to a Gleason 8 or 9 (don't have the paper in front of me right now) before the doctor got worried. As far as I'm concerned, by 45 years old or you need a PSA AND a digital exam. Most guys might be OK with just the PSA, bot NOT all of us.
Posted 4/4/2017 5:24 PM (GMT 0)
Redwing57 ----- extremely well said.

birdmove ------ very good point on having the PSA AND digital exam.

TimOz.----- I think I may have left a comment on the Forbes site. Took five tries .... kept bouncing me out.
Posted 4/4/2017 7:32 PM (GMT 0)

Redwing57 said...
JackH, that's a little harsh.

One quibble, this statement in the 1st section quoted as common sense uses a word that I think is at the core of the confusion/argument: "There is convincing evidence that PSA-based screening leads to substantial over-diagnosis of prostate tumors".

I don't think there is over-diagnosis. That would really require false-positive readings of biopsy cores to truly "over-diagnose prostate tumors". In screening, PSA is only, ever, and always, an indicator for biopsy or disease status; PSA is never diagnostic for tumors. One could argue it sends too many for biopsies, with a high rate of negatives. But a false positive biopsy would be the only way I see as "over-diagnosis".

On the other hand, over-treatment is a definite possibility, and is what we really have to work on.

...

Education is key. ....



Hi Redwing,

Isn't your quibble with the AAFP rather minor...based on your quoted comments, above, of over-diagnosed vs. over-treated? I think that AAFP has an outstanding guideline that the educated and informed "veterans" of patient-oriented groups (put HW/PC in that group) should strongly endorse. Would you feel better about it all if AAFP had said (same, but with a 2-word addition):

JackH said...

(1)There is convincing evidence that PSA-based screening leads to substantial over-diagnosis and over-treatment of prostate tumors. (2)Many tumors will not harm patients, while the risks of treatment are significant. (3)Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients.

I appreciate level-headed dialogue on topics important to men with PC, so I'd invite you to comment on the 3 sentences one at a time, but take the guideline as a whole. I'm honestly baffled when I hear informed voices objecting to this as if doctors were out to get 'em. I agree with your comment (which was basically your agreement with my earlier comment) that "education is key," which syncs precisely with the AAFP guideline...sentence (3).



You don't like the metaphor of the "idiot light?" (I can't remember where I read that.). I think it's a clear description of the general interpretation of the USPSTF guideline, which I view as inferior to the AAFP. It's an insult, put out there to protect all of us against the unwitting actions of a few. I think that deserves harsh language. But maybe that's just me.

Post Edited (JackH) : 4/4/2017 1:56:44 PM (GMT-6)

Posted 4/4/2017 7:55 PM (GMT 0)
Jack, I'm not taking the bait. Enjoy.
Posted 4/4/2017 8:21 PM (GMT 0)
BTW, Redwing, you aren't alone in getting hung up on the work "over-diagnosis," there's a whole BJM article about the definition which starts like this:

BJM said...
The implicit social contract underpinning healthcare is that it will reduce illness and preventable death and improve quality of life. But sometimes these promises are not delivered. Sometimes health services take people who don’t need intervention, subject them to tests, label them as sick or at risk, provide unnecessary treatments, tell them to live differently, or insist on monitoring them regularly.1 These interventions don’t improve things for people; they produce complications or illness, reduce quality of life, or even cause premature death. Active health intervention is not always a good thing: it can be “too much medicine,” or produce what is often called overdiagnosis. Although the concept of overdiagnosis has been described in the literature for nearly 50 years in relation to cancer screening,2 3 it was Welch and colleagues’ 2011 book, Overdiagnosed: Making People Sick in the Pursuit of Health, that popularised the term.4

Overdiagnosis is now an acknowledged problem for patients, clinicians, researchers, and policymakers; it is discussed in journals5 6 7 and at specialist conferences8 and addressed through policy and practice initiatives.9 10 11 There is, however, no formal, agreed definition of overdiagnosis. Rather, the word has become a banner under which disparate people with similar general concerns can unite. This vagueness and breadth allows the appearance of unity but does not serve the more exacting demands of research and healthcare. Here we examine the meanings of overdiagnosis more closely and discuss related challenges for healthcare professionals, patients, and researchers. If overdiagnosis is to be understood and mitigated, the …


I don't think you are putting your head in the sand about whether "over-diagnosis" is a thing or not ("smoverdiagnosis")...but at the same time, I think either/or/both terms apply to the AAFP guideline. Whadyathink?
Posted 4/4/2017 8:31 PM (GMT 0)
What about this definition:
"Overdiagnosis is the diagnosis of "disease" that will never cause symptoms or death during a patient's ordinarily expected lifetime. Overdiagnosis is a side effect of screening for early forms of disease."
Posted 4/4/2017 10:11 PM (GMT 0)
This is degenerating into something of a semantics argument.

Railing about "over-diagnosis" is an excuse to stop screening. I am in favor of screening. It's up to the medical community to educate the patients about the results of the screening. That it has gotten this far is an abject admission of failure on the part of medical professionals in their relationships with patients.

I think it is arrogant, unfair, and bordering on the unethical, to say "People are idiots and don't respond properly to information from screening. Therefore we stop screening.". That's ridiculous, and offensive. As one who would have a very serious situation on my hands without screening, obviously I cannot be passive about this idea.

Educate the people. Do better at the interpretation of screening. Don't frickin' stop screening.

[Edit:]Oh, ok, and to the three sentences, I'll try:
(1)There is convincing evidence that PSA-based screening leads to substantial over-diagnosis and over-treatment of prostate tumors.
Nope. Still only agree with over-treatment as an issue. No such thing as over-diagnosis in this context.

(2)Many tumors will not harm patients, while the risks of treatment are significant.
Absolutely. Totally agree. However, not related to whether or not to screen via PSA. Still an argument about how one responds to information, not whether the information should exist.

(3)Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients.
Nonsense. Cowardice. Even irresponsibility. When is a physician not to engage in shared decision making? What kind of arrogance does this assume about physicians? What condescension toward patients! If this is actually a problem, then it is only a symptom of a MUCH larger problem.

Very frustrating discussion.
Posted 4/4/2017 10:22 PM (GMT 0)
It sounds like you agree with (1), (2) and (3)

Right?


Or which part of which one don't you agree with?

Again, we all appreciate your level headed discussions.
Posted 4/4/2017 10:39 PM (GMT 0)
so what constitutes overtreatment? from what I've seen it's a guy who has been "cured" who is bitter about SEs or his life in general after diagnosis and successful treatment.

i have never heard a guy fighting for his life or some extra time say he was overtreated.

ed
Posted 4/5/2017 12:24 AM (GMT 0)

F8 said...
so what constitutes overtreatment? from what I've seen it's a guy who has been "cured" who is bitter about SEs or his life in general after diagnosis and successful treatment.

i have never heard a guy fighting for his life or some extra time say he was overtreated.

ed

Yeah, I think that's about right. A guy living with side effects he didn't need to have, from any of the life-altering treatments available, for a cancer that never would have affected his life, would have been over-treated. That's kind of what I've been thinking the term means anyway.

There's cost to treatment, both in real dollars, lost productivity, emotional, relational, whatever. Now, some folks may be so freaked out by the C word that they'll take and live with virtually any treatment fallout. In their mind, "It saved my life.", whether it really did or not, they're ok with the side effects because "it had to be done.". Others may realize their reduced QOL was unnecessary, and become upset about it with the perspective of time. I've told a lot of folks to keep in mind the prostate is the junction block for their whole system. Everything down there either goes through it, is in it, on it, or attached to it. You don't just pop the little rascal out without affecting everything else to varying degrees.

The real cost to the insurance companies is inarguable. Every dollar they don't spend on intervention payouts goes to their bottom line, because they're sure not reducing premiums. If they can convince 1,000 men not to be screened, and just let one of them simply die at little cost to them, they're ahead (the ratio seems to be in that neighborhood). In a cynical green-eye-shade accountant viewpoint, let 'em die, and increase the insurance company's shareholder value.
Posted 4/5/2017 12:35 AM (GMT 0)
Redwing, yep. Absolutely. And I come back to the 15 minute office visit as the standard of care. And who drives THAT metric?

Sure, patients SHOULD become more involved in their care decisions, and I note, yet again, that this particular group is a self-selected group of people who are generally above average in their commitment to learning about PC.

It is still, always, and must always be the PHYSICIAN'S responsibility to make sure the patient has all the information they NEED (frequently more than they want) to make informed decisions.

I just looked up on Wikipedia the 'modern hippocratic oath', and it includes this line:

".....I will neither subscribe to overtreatment nor therapeutic nihilism...."

Overtreatment is not the patient's fault. If the patient is demanding overtreatment out of fear, or ignorance, or from family pressure, or social pressure, or whatever other cause, it is the responsibility of the treating physician(s) to shout STOP and refuse to treat. They don't, and they probably won't. (Some do) But that's what they are pledged to do.
Posted 4/5/2017 1:33 AM (GMT 0)
I always took the USPSTF guidelines as a slam against physicians rather than patients. I believe their thought was: It is too difficult to retrain physicians on how to correctly use PSA results to treat only the patients that need to be treated. Since over treatment is more likely to occur rather than intervention saving lives, they recommended against routine use of the test.
I was shocked with how little my urologist knew about the proper treatments of PC (1) cancer comes back with radiation so you should cut it out (2) Radiation causes secondary cancers especially if you are receiving it in your 50's. (3) Active surveillance is dangerous and leads to metastatic disease.

There are a low percentage of physicians that over treat because of the money. I think there are far more that over treat because they do not know any better.
Paul
Posted 4/5/2017 1:34 AM (GMT 0)
Everything that Redwing said.
It's absurd to be pitting this on the patient. It's not up to the USPTF or anyone else, to decide what we should know or not know about our health.
And it's not up to the patient to know what the information means, great if we can, but not everyone has the capacity, or the means. that's why God invented Doctors. To help us understand. Not to prevent us from obtaining knowledge.

It's on the medical profession to diagnose AND educate their patients. It's really so simple
Posted 4/6/2017 4:02 PM (GMT 0)
I read a book recently—I highly recommend it—called Being Mortal by Dr Atul Gawande. It contained this great passage about what we are talking about here:

    “The oldest, most traditional kind is a paternalistic relationship - we are medical authorities aiming to ensure that patients receive what we believe best for them. We have the knowledge and experience. We make the critical choices. If there were a red pill and a blue pill, we would tell you, ‘Take the red pill. It will be good for you.’ We might tell you about the blue pill; but then again, we might not. We tell you only what we believe you need to know. It is the priestly, doctor-knows-best model, and although often denounced it remains a common mode, especially with vulnerable patients - the frail, the poor, the elderly, and anyone else who tends to do what they’re told.

    The second type of relationship the authors termed ‘informative.’ It’s the opposite of the paternalistic relationship. We tell you the facts and figures. The rest is up to you. ‘Here’s what the red pill does, and here’s what the blue pill does,’ we would say. ‘Which one do you want?’ It’s a retail relationship. The doctor is the technical expert. The patient is the consumer. The job of the doctors is to supply up-to-date knowledge and skills. The job of the patients is to supply the decisions. This is the increasingly common way for doctors to be, and it tends to drive us to become ever more specialized. We know less and less about our patients but more and more about our science. Overall, this kind of relationship can work beautifully, especially when the choices are clear, the trade-offs are straightforward, and people have clear preferences. You get only the tests, the pills, the operations, the risks that you want and accept. You have complete autonomy.

    In truth, neither type is quite what people desire. We want information and control, but we also want guidance. The Emanuels described a third type of doctor-patient relationship, which they called ‘interpretive.’ Here the doctor’s role is to help patients determine what they want. Interpretive doctors ask, ‘What is most important to you? What are your worries?’ Then, when they know the answers, they tell you about the red pill and the blue pill and which one would most help achieve your priorities. Experts have come to call this shared decision making.”



The shared decision making process (as espoused in the AAFP Guideline) is described in one New England Journal of Medicine article as "the pinnacle of patient-centered care." The pinnacle. I think, guys, that it's the way things are going today. Those of you who continue to yearn for the "paternalistic" approach are going to find fewer and fewer doctors practicing that method today...it's on it's way out, and bordering on being an ethical question. Doctors today are being taught this approach (see, for example, this Journal article "Shared Decision Making: A Model for Clinical Practice"...the details of educating patients is better described in this article (plus a PC case example) than in the short book passage quoted above which is described in an end-of-life context. More-and-more medical Guidelines will follow the lead of AAFP and integrate this principle directly into their mantra. I'd suggest you also familiarize yourselves with it for better satisfaction with medical care in your own future rather than continue to fight it and frustrate yourselves.

In case you haven't actually read the article from the original posting and this needs to be pointed out, the Guideline under discussion here does not say any of these sky is falling statements (all quoted from recent posts, above):
* we will "frickin' stop screening"
* only doctors will "decide what [you] should know or not know about [your] health"
* our goal is to "prevent [you] from obtaining knowledge"

For those interested in learning more, I recommend that you Google this 4-word string: shared decision making ethics

Post Edited (JackH) : 4/6/2017 1:34:02 PM (GMT-6)

Posted 4/6/2017 4:37 PM (GMT 0)
The paternalistic....as I've gotten older...they may be good doctors...fantastic doctors...so, I may be cutting my nose off to spite my face in some cases. It's just gotten to where if they're paternalistic, I find myself in the role of taking care of their needs (and that's if I'm in a good mood). Then I leave not knowing if I can trust what I've been told.

"Good help is hard to find" doesn't just apply to unskilled labor.

It's a human thing. Not profession specific.
Posted 4/7/2017 2:59 AM (GMT 0)
Where I live, I can just get my own test. No doctor order required, just need a few $, maybe $45-50? Also, it can be done mail order through places like Life Extension. Of course, that does not mean I would know to do it without a doctor telling me I should, many would not. One thing about having your own done: less risk of over treatment.
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