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Posted 3/10/2010 5:14 PM (GMT 0)
Below is yet another article indicating how over treated PCa is. This one from the man who discovered PSA. These articles have now surpassed being a trend to becoming a wave IMHO.

http://www.nytimes.com/2010/03/10/opinion/10Ablin.html?scp=2&sq=PSA&st=cse

Posted 3/10/2010 6:00 PM (GMT 0)
Thank you for posting the link to this article.

Zen9

Posted 3/10/2010 7:56 PM (GMT 0)
realziggy - thanks for posting that link - I was aware that Professor Richard J. Ablin was trying to distance himself from P.S.A. testing - but don't they read their own articles ... the phrase that got me was:
"Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. "

RETURN of the DISEASE?

Is that not like closing the barn door after the horses have bolted?

I never thought of P.S.A. as being the main test but one that could lead to further testing if necessary. If I had a dumbass-just-for-the-money doctor I would still have my prostate - peeing when I want and having a very happy Mr. Happy since my PSA was within the safety margins for my age.
But because my doctor and urologist CARED about me and my life - I had further testing and Prostate Cancer was found.

Ablin talks about the companies that benefit from the P.S.A. testing, but in fact is it not those treating men after the fact who are reaping the benefits - and again, the listing of percentages - "3% chance of dying from it" - tell that to the families of the 30,000 men who do die from it every year....

When I see articles like this I flash back to the old "Smothers Brothers Comedy Hour" and the song - "four steps forward and two steps back "...

Argh and a hug

BRONSON
Posted 3/10/2010 8:25 PM (GMT 0)
Bronson - I agree fully with your sentiments here on this one.

David in SC
Posted 3/10/2010 8:35 PM (GMT 0)
Another one of the co-discoverers of PSA, Stamey, has an opinion similar to that of Ablin. I'm not saying I agree with them (or even qualified to give an opinion) but this is something to think about. I heard Stamey at an US Too meeting talk about this view. The following is from a September 2004 article "Common test for prostate cancer comes under fire" in the Stanford University News.

http://news-service.stanford.edu/news/2004/september22/med-prostate-922.html
(excerpts below)

“Our study raises a very serious question of whether a man should even use the PSA test for prostate cancer screening any more.”

The findings reflect a shift in Stamey’s thinking from 1987, when he published the original findings in the New England Journal of Medicine that linked increased blood PSA levels to prostate cancer. Over the years, Stamey has come to believe that the PSA test is no longer a useful predictor of the amount or severity of prostate cancer...Stamey explained that the change in his thinking is due to the increased screening for prostate cancer. Now that screening is more commonplace in this country, many cancers are being caught earlier and are usually smaller – not generating enough PSA to be a good indicator of severity. By contrast, he said, the tumors encountered 20 years ago were generally so large that they generated PSA levels high enough to provide a reasonably good measure of cancer severity....

“Almost every man diagnosed with lung cancer dies of lung cancer, but only 226 out of every 100,000 men over the age of 65 dies of prostate cancer,” he said, referring to National Cancer Institute statistics.

Stamey explained the basic dilemma as such: men whose PSA levels are above 2 nanograms per milliliter frequently undergo biopsy, which will almost always find cancer. These results do not necessarily mean that prostate removal or radiation treatment is required. “What we didn’t know in the early years is that benign growth of the prostate is the most common cause of a PSA level between 1 and 10 ng/ml,” he said.

A number of physicians question Stamey’s findings and contend that the test should continue to be used. Stamey disagrees. “Our job now is to stop removing every man’s prostate who has prostate cancer,” he said. “We originally thought we were doing the right thing, but we are now figuring out how we went wrong. Some men need prostate treatment but certainly not all of them.”
Posted 3/11/2010 1:17 AM (GMT 0)
Thanks for posting. I'm amazed at how PSA test is being bashed. None of us would have had surgery or radiation just by having a high PSA. A high PSA leads to further tests which may or may not show the presence of cancer. All of us on this site, started our journey because of a high PSA or a high PSA velocity. If it wasn't for the PSA test some of us could be dead by now.
Posted 3/11/2010 1:45 AM (GMT 0)
I get my testing done at Quest, I think the price is more like $25 not $100, I really do not see how this is such a waste of money.  Typically after 45 the doctor wants a check up every year and the check with the other regular stuff.  Why is everyone picking on prostate cancer,  we hear people every day who die of it. 
Posted 3/11/2010 3:18 AM (GMT 0)
A biopsy with an elevated positive result puts the PSA issue to rest. PSA simply gave me the heads up. When a gleason comes in at 8 following an elevating psa, then the rest is a bunch of bull. Gleason 8 is not a debatable matter. This sounds like the same story as the mammography bull from HHS. Go meet a breast cancer patient and you'll cringe at how HHS can be so ridiculous to the obvious about getting screened. To further confirm the obvious, look at the PC survival rates; they have sky rocketed.
Posted 3/11/2010 4:14 AM (GMT 0)

Redman55 said...
A biopsy with an elevated positive result puts the PSA issue to rest. PSA simply gave me the heads up. When a gleason comes in at 8 following an elevating psa, then the rest is a bunch of bull. Gleason 8 is not a debatable matter. This sounds like the same story as the mammography bull from HHS. Go meet a breast cancer patient and you'll cringe at how HHS can be so ridiculous to the obvious about getting screened. To further confirm the obvious, look at the PC survival rates; they have sky rocketed.

Where are these PC survival rates that have sky rocketed?
Posted 3/11/2010 5:18 AM (GMT 0)
The best place to go to see prostate cancer survival rates and statistics is the SEER information portal at the National Cancer Institute. I have reviewed most of the stat sheets at this site and while not a huge drop in mortality since the PSA test began being used, there has been a significant drop in mortality since the mid 80's. If you compare back into the early 80's and 70's, the drop is very significant. But you have to remember that almost all prostate cancers were diagnosed in late stages. Death annually from prostate cancer in those days was as high as 46% of annually diagnosed cases. Today it's closer to 14% (using the NCI projections of est. 28,000 deaths in 2010, versus est. 210,000 will be diagnosed)

The chart I have linked shows death by prostate cancer trending upward by 3% for the 4 year period 1987 to 1991. It also shows mortality decreasing 4.1% in the 12 year timeframe from 1994-2006. That would indicate a 7.1% drop in mortality trend rates when PSA usage became more widespread.

seer.cancer.gov/statfacts/html/prost.html

One could argue that improvements in treatment are in part responsible, and I would agree with that to some degree. But just a thought? Where would funding come from for treatment research if we reduced the number of men diagnosed? What impact would there be on funding grants if only 65,000 men per year were diagnosed (1985 stats) per year versus 210,000 per year (2010)? These are logical questions if you take away PSA testing.

As for me, I am very frustrated right now about the whole argument. I am ready to throw in the towel and just live with the perception from many in my community feel that diagnosed at the age of 44 with advanced prostate cancer I am in a category that is considered over-diagnosed...:-(

Tony
Posted 3/11/2010 11:19 AM (GMT 0)
It's interesting how those of us who have had the disease seem to understand the role of PSA better even than its inventor.  There seems to be a common misunderstaning among these articles: that a man gets an automatic PSA test, and if it's over 4 they are subject to needless treatment that can ruin their quality of life.  I can understand the average person on the street falling for this misconception but experts such as the one in the article know better.  And even if they don't explicitely state the misconception, they certainly fan those same flames.

In reality, as we know, PSA is only an early indicator that something may be going on that needs to be checked out.  It may be PC, but more likely it's an infection, BPH, or nothing at all -- maybe just riding a bike or having sex just before the test.  A repeat high PSA, especially a higher one, might indicate the need for a biopsy.  And this about a "painful" biiopsy, especially coming from a doctor, is alarmist and utrue.  Sure, there are painful biopsies, just as there are painful tooth fillings.  But no one would argue that a filling is painful therefore don't have one if you need it.  I didn't feel a thing during my biopsy.  My uro game me a shot and, other than a tiny twinge from the needle, no more than when getting a flu shot, I felt nothing.  If there is a problem with paiful biopsies, I'm sure medical science can fix that very easily.

Even after a biopsy, no treatment may be needed.  It might be negative, or it might show cancer at such an early stage that watchful waiting is appropriate.

It's only for cancers that are aggressive, or could turn aggressive, that action is needed.  Can they tell us which are which?  Not perfectly but, without PSA to kick start the process, we can be sure that every cancer they found would be aggressive, because it would be found at such a late stage that it would be giving us symptoms.

So I don't understand what is driving all these PSA articles lately, but I'm glad a routine PSA test started a process that found multiple cancers in my prostate that would have escaped within another few months.  I feel sad for all of those men who will be scared away from PSA testing by these articles.

Posted 3/11/2010 2:38 PM (GMT 0)
Lest I sound like a doomsday nitwit who keeps a month's supply of food stashed at various places, let me assure you that I am not one of those people. To me the whole flap is about dollars and cents, pure and simple. There is only so much money for health care available, and everyone wants a bigger share of the pie. The government holds a big share of the pie and wants to keep it. The drug companies want their share, the labs want theirs, and the hospitals will take all they can get. What about the doctors? Can you imagine his liability exposure if your urologist said, "forget about the high PSA"? I am not a lawyer, but I could win that jugement. Even if the biopsy shows an indolent form of PCA, who is to say that a few cells over from the needle path there is not a focus of Gleason 9? It is not just cut and dried, folks. No way.
I believe it is important to concentrate on the "ones". The "ones" are the patients, not a study group but one patient, YOU. When you show up with back pain, shortness of breath, urinary retention, or even paraplegia, it will be 100% YOU. When your x-rays look like someone has been in a snowball fight with your spine and lungs, it will be 100% you. When go toes up before you should have died, it will be 100% you. Forget the numbers games.
The cost of a PSA is likely ten times what it really is. You won't mind that a bit, if one leads to the early treatment of a malignancy. One should at least have the option of choosing his treatment and care of his body.
Do you really think that some academic at whatever U. is going to give a flying flip about you, as you leave this world ahead of time? How about the next ten guys here with a newly elevated PSA go by their senator's or representative's office and discuss their next move with them? Makes just as much sense to me. I DID read the article too.
Posted 3/11/2010 4:22 PM (GMT 0)
This is such a complex issue. The information on the outlook for people with prostate cancer isn't all there. What are the odds for someone with untreated, but small prostate cancer of getting bad disease in 20 or 25 years? Most studies, including the European screening study that says there is a 1/48 chance of saving a life with screening, don't go very long--in that study, no patients more than 10 years. Also, no doubt that people get surgery or radiation for prostate cancer that doesn't help them. Since PSA screening has been around, the death rate from prostate cancer has gone down a lot, but there are several times more people getting surgery or radiation for each life saved. There are 3 common situations where prostate cancer treatment may not save many lives:

1. small, low grade tumors. Most probably won't die from prostate cancer even in 25 years. A few will. How many? It's not certain.
2. individuals where there is extensive spread outside the prostate. Many of these people will have recurrence somewhere else, even after surgery and radiation. Some won't. How many?
3. people over 65 to 70. The Scandinavian study showed that people over 65 who were randomized to surgery or watchful waiting, did not live any longer if they had surgery. Maybe this is because they didn't live long enough to benefit from the surgery. Maybe by that age it's already spread to other places. But that doesn't mean that there aren't some individuals who benefit from treatment, even at this age, but they might have to live into their 90s to realize the benefit.

The problem is, that these studies are all about odds. Everyone is an individual, and most people don't want to roll dice on the risk of terminal cancer. If there was a perfect treatment, with no risks or complications, it'd be easy, everyone would get treated. The risks of treatment are significant, and I think that this forum has more people on it who have had problems, because people who are doing well tend to move on and not think about their prostate as much.

In my case, I was sort of in group 1. I opted for surgery because--1. every year my PSA went up, my prostate got bigger, I had more trouble urinating, I just didn't want to face years of biopsies and more and more symptoms. 2. I was a really healthy 57 year old, which meant I had a better chance of doing well with surgery, and also of living a long time (lots of relatives in their 90s). 3. My wife and family were freaked out by the whole thing, and it's reassuring to them that had the surgery. also...4. I knew a really good surgeon, with good inside information as to his skill. So far this is a bet that's worked out for me. The complications are not severe (no incontinence, ED correctable with pills), and getting better (9 months out), and they are more than counterbalanced by the fact that I don't have urinary obstruction any more. Reading this forum make me realize that I've been very, very lucky, probably more lucky than smart. So, even though this has worked out for me, I think that's its important that anyone with a new diagnosis of prostate cancer think very very very carefully because deciding on treatment, and I can certainly understand why some people would chose just to watch their prostate, to just take Avodart, or not even get screened in the first place.
Posted 3/11/2010 6:40 PM (GMT 0)

Interesting article and interesting topic as always when we talk about PSA testing...

I remain in the camp of those who favor routine PSA testing because of my personal philosophy of trying to obtain knowledge to help make good decisions.  However, the longer I am around this disease, the more I think I understand the POV of those who are on the other side of the coin.  I say this for two reasons:

1.  I have seen numerous examples of early stage patients who are treating the anxiety more than they are treating the patient (full recognition to realziggy for coining that phrase).  Even today one of our new posters commented, "... I want it out YESTERDAY!".  Clearly there is lots of overtreatment going on and the the original source of the anxiety starts with PSA results.

2.  There are many docs who are rushing their patients into treatment even though the patient may be early stage.  I will pass on making a value judgement about whether all of these docs are practicing good medicine or some may be trying to amortize the costs of their new robots over a larger patient base.  Forgive me for being skeptical when I spend the winter in South Florida and am bombarded daily by billboards as well as newspaper and radio ads where (mostly robotic) docs are trolling for business.

I certainly do not have the answer but IMHO it is not black and white --- rather it is a complex issue that will probably not be solved until we have better tests that measure the aggressiveness of the cancer.

Tudpock

Posted 3/11/2010 8:09 PM (GMT 0)
Statistics are a wonderful thing and can say pretty much what you want them to say in a situation like this. The trouble is that a 1%, 10%, or 25% chance of dieing does not mean you will only be 1%, 10%, or 25% dead. I had a brain tumor several years ago. The literature said I only had a 1:100,000 chance of getting it. After beating those odds the 95% chance of a cure was not as comforting as it might have been.
I believe more information not less will identify costs that can be saved from over treatment. Unfortunately, too few recognize the abyss that you go over if you go too far down the over treatment path. An argument can be made that money spent simply to prolong some one's life a month or two is over treatment. Treatment that is not curative could be considered over treatment. Treatment for you and yours as opposed to me and mine is over treatment. It goes on. Somebody would be making those calls and I'm fairly confident it won't be anyone registered here.
Posted 3/11/2010 9:16 PM (GMT 0)
The problem is not the actual PSA testing it's what happens after the tests. Many times a biopsy is done and a lot of guys with low risk numbers rush to radical treatment. In fact we just had a 49 year old here with extremely low risk numbers including a gleason 2+3=5 who right after his biopsy was getting the usual pressure from doctors for radical treatments still. No doubt PSA has saved some lives but how many more have had their lives turned upside down and their quality of life degraded? How many relationships have suffered due to sexual problems afterward? I understand the emotional appeal well if you're one of the 3% who were saved but most just ignore if you're one of the 97% who went through all this, who never had to? Many are guys here who are in denial that they may well have been one of those. That's only human nature and maybe why it's easier for me with a far less invasive treatment to admit maybe I would've been better never to have taken that routine physical back in 2007.

There's is a recent trend with AS being accepted more and more. It wasn't too long ago anyone here doing AS would get responses of their being in denial or taking great risks. Or the still ever present to get that out of you RIGHT FRIKKN NOW!!!

I'm hopeful soon more doctors will recommend AS or at least show the survival numbers after dx for those with low risk numbers.

Post Edited (realziggy) : 3/11/2010 2:22:14 PM (GMT-7)

Posted 3/11/2010 10:04 PM (GMT 0)
Selmer,
There is no question that PSA screening saves lives. As someone pointed out 1 in 48 men diagnosed with PCa through screening will be saved. However, it's apparently trending to a community that feels that rather than better educate the other 47 men, it's better to let the one man go... I hate putting it that way, but that's what it seems like to me.

I just spoke with Mike Scott from the InfoLink this morning and he is willing to try to provide a nudge back at the medical and advocacy community to be more consistent about screening, as well as urging organiztions to do a better job educating men. I expressed to him that I personally feel that too many professionals and organizations are enjoying their air time in the controversey and neglecting the parts of their mission statements about education.

Tony
Posted 3/11/2010 10:59 PM (GMT 0)

Tony

You put it exactly right!! 

Another article that I hated reading!!  And from the discoverer of PSA.  How sad.

Why is the New York Times on this anti PSA bandwagon??

I guess I know the answer with the great health care debate going on in the States.

Skeener

Posted 3/11/2010 11:24 PM (GMT 0)
"Still, 3.8 percent is a small number. Nevertheless, especially in the early days of screening, men with a reading over four nanograms per milliliter were sent for painful prostate biopsies. If the biopsy showed any signs of cancer, the patient was almost always pushed into surgery, intensive radiation or other damaging treatments."

The fallacy of this article can be boiled down to the last sentance in this paragraph. Who in their right mind wouldn't want (or deserve) to know if they have cancer??!! If so, as in my case, the whole range of options, including WW, RT, and prostatectomy was explained and later researched by yours truly. I was not "pushed" into anything. I think few patients are judging my the comments on this forum. An assumption that men are too ill-informed or too unintelligent to make their own choices in this matter is condescension in the extreme. It also casts the medical profession in a poor light, suggesting that almost always rapacious medicos treat their pockets first and the patient second. I personally do not believe that. If we stop widespread screening based on this type of thinking then the future holds untold thousands of cases of PCa which will escape the prostate, metastasize, and unnessarily kill.



Steve
Posted 3/11/2010 11:51 PM (GMT 0)

Tudpock,

I think your post was one of the best, most concise summaries of a very complex phenomenon.

I am happy I got tested (despite ultimately losing my marriage and my career), and I encourage my friends to do so.  And I certainly do not want anyone telling men they can't get tested (or that insurance won't pay for it).

HOWEVER - there are at least two real problem areas currently:

1. Too many doctors use a patient's intense anxiety about a new cancer diagnosis to rush him into surgery, radiation, or whatever the doctor specializes in.  I've experienced it myself and I have seen it too often with other men I know.  Very few men can stand up after being diagnosed with cancer and say, "No, stop, I want to think about this."  What is going on is reprehensible.

2. As Dr. Otis Brawley has eloquently written (not that I expect anyone on this board to care what he thinks), it is comparatively easy to get funding to study ways to make a better robot or to start yet another program to encourage more men to get tested but next to impossible to get funding to explore which prostate cancer tumors are truly dangerous and which are not.  Why?  Because if we knew that, many medical centers couldn't pay for their expensive equipment and urologists' and radiologists' incomes would fall dramatically to pre-PSA testing levels.

There are a few doctors - Scardino, Stamey, etc. - who are trying to follow their consciences rather than their pocketbooks - and they have my complete admiration - but not enough.

Zen9

 

Posted 3/12/2010 1:43 AM (GMT 0)
If anything I would raise the accepted PSA level, maybe 5 maybe 10. But the 20 plus guys need to know now ASAP. But once you are diangonosed , I can understand while some people would like to do AS, but on the other hand AS is also an expense and an inconvenience. In the long run I think it would cost more, imagine 25 years of biannual checkups.

My personal view, which is me only is that I did not like the drugs, I did not like the idea of 6 month testing programs, I did not want to spend a lot of money just watching, just cut the dang thing out and lets get on with life.
Posted 3/12/2010 2:26 AM (GMT 0)
Hi to everyone ! I;m so tired of everyone thinking that Pc is a joke!!!had it not been for psa testing and the DRE I might not have my husband today!!! and if our family dr. had been more agressive about the test {psa] my husband pc would have been found sooner rather than later!!!!!!!and he wouldn"t have had to undergo the surgery.SRT and all the other mess, people who think Pc is a good cancer to have should walk in some of your shoes and your families shoes and all this nonseence about psa testing and over treament would stop my thought is 1 life saved is worth it P.S. sorry if i said tomuch
DEERHUNTERS WIFE
Posted 3/12/2010 9:18 AM (GMT 0)
<<<Too many doctors use a patient's intense anxiety about a new cancer diagnosis to rush him into surgery, radiation, or whatever the doctor specializes in. I've experienced it myself and I have seen it too often with other men I know. Very few men can stand up after being diagnosed with cancer and say, "No, stop, I want to think about this." What is going on is reprehensible.>>>>

In my experience outside the USA and in Europe, I was hit from day one with advice about taking my time, choices of treatments or nothing at all, second and third opinions, etc. Everyone from GP to operating surgeon wanted me to hear their spiel on this. I finally began to cut them off and tell them what I wanted without more discussion. I was never remotely given a "hard" sell. If a PCA patient cannot recognize a used car salesman in a white coat, then he needs a keeper.

<<<<<As Dr. Otis Brawley has eloquently written (not that I expect anyone on this board to care what he thinks), it is comparatively easy to get funding to study ways to make a better robot or to start yet another program to encourage more men to get tested but next to impossible to get funding to explore which prostate cancer tumors are truly dangerous and which are not. Why? Because if we knew that, many medical centers couldn't pay for their expensive equipment and urologists' and radiologists' incomes would fall dramatically to pre-PSA testing levels.>>>>

This is simply paranoia at its best. Dr. Brawley may have his sour grapes if he isn't great at getting funding, but I do not believe for a minute that there is a conspiracy between doctors, hospitals, or anyone else to line their pockets with healthcare dollars obtained through such means. Some of you folks need to talk with your feet when such horse feathers start to fly.
Posted 3/12/2010 12:43 PM (GMT 0)
I was diagnosed and treated in 2006.

At the time, I had a concern that treatment may be unnecessary.

I'll never know if it was unnecessary or not, but I still have that concern.

One of the problems I had was knowing I had cancer.  I couldn't not pursue what I thought was my best chance for a cure.  I have great admiration for those guys that do AS.  I couldn't do that.

So, I don't regret getting treatment once I was told I had cancer.  But I'm thinking maybe I'd have been better off never knowing I had it in the first place.  I don't know if the PSA saved my life or just made it worse.  In some cases, it's made lives significantly worse.  Looking at the statistics, it would seem I may have been better off not knowing.

If the stats are correct, it's hard to argue that this thing is being overtreated. 

Dave

Posted 3/13/2010 2:09 AM (GMT 0)
Hi Guys

I keep reading the debates about treat or not treat your cancer. What would guys consider PSA and Gleason scores to treat or not to treat?

Mika
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