Alarming rise in PCa as testing declines.

Makes perfect sense to me. How could it not?

At my last colonoscopy, one of the nurses who took my history and prepped me, looking at my history (numerous regular scopings, a history of polyps, and both parents with colon cancer), said "Well, you're not going to die from colon cancer!" She meant, of course, that any polyps would be removed as usual, and any carcinomas that did form would be caught very early.

The 9 or so prostate biopsies I had over some 25 years because of a fluctuating, but slowly increading PSA from notable BPH, was almost certainly the reason my G9 (5+4) PCa was caught early, with a pT2 surgical result and negative margins. How easy it would have been for me to have said after any one of my many negative biopsies "Enough with the biopsies -- they always come back negative -- I don't have cancer!"

The moral as I see it is to be egoistical and proactive when it comes to screening in general and especially PSA, which is easy to do. "Only" about 20% of PCa diagnoses are high-risk, but PCa is common, and the older you are, the higher the risk your PCa is, in fact, high-risk. A British study a few years ago proposed that the upper limit of the normal PSA range be 3 and not 4, i.e., anything above 3 warrants further investigation. Uro's are attuned to screening, of course, but from what I see on forums, GP's seem to dismiss higher PSAs (with a "Don't worry about it") rather than refer their patients to a uro.

The answer to the "overtreatment" argument is active surveillance and not reduced screening.

I know that posting this here is preaching to the converted, but don't pass up the opportunity to promote PSA screening when it comes up with your friends: early diagnosis is the first line of defense.

Djin

about a month ago I had my annual physical. I kept the appointment because, well, its been an eventful year (see my signature).

I thanked my regular Dr several times. He started screening my PSA when I was in my 40’s. I am now 53. He was the one who sent me for a consult because my psa went from 1.9 to 3.1.

He literally gave me a chance to win.

F8, he was only one of several individuals who incessantly stirred the overtreatment pot. I still tell guys my age (and younger now) to get a PSA and a DRE annually. And then tell them, if they get a high reading, to let me know and share what I know about it.

(I started getting annual PSA and DRE in my 40's)

In the short time I’ve been a member of this choir, I’ve used my new story to tell every guy I can about how a lucky, unscheduled blood test that happened to include a PSA test (for the first time in my life) saved my bacon, or at least gave me a decent chance to fight the beast. And that they owe it to themselves and their loved ones to get tested regularly and discuss with their docs.

Absent that serendipitous test, there’s every likelihood that I would still be sailing merrily along, apparently healthy without any knowledge of the dangerous trouble growing below.

Stephen S said...
about a month ago I had my annual physical. I kept the appointment because, well, its been an eventful year (see my signature).

I thanked my regular Dr several times. He started screening my PSA when I was in my 40’s. I am now 53. He was the one who sent me for a consult because my psa went from 1.9 to 3.1.

He literally gave me a chance to win.

Yours is an interesting story. And during the lock down! Good on your doc for paying attention to that rise from 1.9 to 3.1!

I think most of us have similar viewpoints on the value of PSA. I was in my 40's (about 45 I think) when I asked my PCP for PSA and DRE as part of my annual physical and bloodwork. He was ok with it, after he asked why. My response: My father has PCa, had been in and out of treatment for several years at the time, and I wanted to make sure, with my history, that if I was going to develop it, I wanted to catch it early.

The rest is history.

Michael_T said...
The communication about not testing had a negative effect on me. I had a high-ish PSA in my late 40s and a negative biopsy in 2007. Between the negative biopsy and all the talk about how PCa was over-treated, I figured I had a "get out of jail free" card. I actually continued to get tests as part of my annual physical, but I ignored the results (as did my doctor), even though my PSA kept increasing. It was only five years later that I reluctantly had a second biopsy--that one hit gold.

I do think that over-treatment can be a problem. A lot of low-risk guys don't seem to know AS is an option. But that's a different issue than testing.

Both a biopsy and an MRI can miss existing PCa. Uro's know that when PCa is strongly suspected, repeat biopsies, or targeted + systematic biopsies are indicated. Even if you assume PCa is missed one-third of the time, this rate drops dramatically as you do repeat biopsies (do the math and you will see for yourself). As I mentioned above, non-uros are often too cavalier about the chance that a high and rising PSA is from high-grade disease.

Hopefully we'll have excellent liquid biopsies in the not distant future, but until then I suggest you assume your uro has your health and not his vacation fund in mind when he advises a/another biopsy is in order

Djin