More Evidence Favoring PSA Screening

From the Johns Hopkins Hopkins Health alert published today:

Jim

"The chances of dying of prostate cancer are significantly lower among men who undergo routine PSA screening compared with men who aren't screened, according to 11-year findings from the European Randomized Study of Screening for Prostate Cancer (ERSPC).

These findings, which were reported in The New England Journal of Medicine (Volume 366, page 981), update and reinforce similar findings from the ERSPC in 2009, but are at odds with those from a large trial known as the U.S. Prostate, Lung, Colorectal and Ovarian study.

ERSPC enrolled 182,160 men, ages 50 to 74, in eight European countries. The men were randomly assigned to a group for which PSA screening was offered but was not required or to a control group that was not offered PSA screening. The researchers found that men who were offered and underwent PSA screening were 29 percent less likely to die of prostate cancer than their unscreened counterparts.

Our advice. Although this study found that the mortality rate among PSA-screened men was lower than for unscreened men, the authors agree with other experts that the risks of routinely screening all men outweigh the benefits. A more judicious approach based on a thorough risk factor assessment and history is advisable. That means every man should talk to his doctor about what's best for him based on his individual circumstances."

Tudpock18 said...
...A more judicious approach based on a thorough risk factor assessment and history is advisable. That means every man should talk to his doctor about what's best for him based on his individual circumstances."

Another reputible organization, one recognized as knowledgeable about prostate cancer, has come out against the  parking lot mass screenings of the past.  Testing is better than no testing...clearly, duh...but a "judicious approach based on a thorough risk factor assessment and history is advisable"...based on the individual.

This is precisely what the AUA, EAU, ACS and NCCN have all recommended.  Stop the parking lots tests by hospital nurses trolling for patients.  Instead, baseline at age 40.  Then. assess risk and history before next step.  Here's what they recommend, based on risk and history...

ACS	Informed decision making	40 years for men at highest risk (several first-degree relatives diagnosed with prostate cancer under age 65 years); 45 years for men at high risk (African American or first-degree relative with prostate cancer); 50 years for men at moderate risk with a life-expectancy of more than 10 years	Men who choose to be tested who have a PSA <2.5 ng/ml only need to be retested every 2 years; annual screening for men with PSA ≥2.5 ng/ml
AUA	Informed decision making	40 years for baseline DRE and PSA	Screening intervals based on baseline PSA
EAU	Insufficient evidence to recommend widespread routine screening; opportunistic screening should be offered to all well informed men	40 years for baseline PSA	Screening interval based on baseline PSA; 8 years generally sufficient for men with initial PSA <1 ng/ml; further PSA testing unnecessary in men >75 years old with baseline PSA <3 ng/ml
NCCN	Informed decision making	40 years for baseline DRE and PSA; 50 years for annual screening	Screening algorithm based on initial PSA and DRE; repeat screening at age 45 years if PSA <1.0 ng/ml

Post Edited (Casey59) : 3/9/2013 8:40:06 AM (GMT-7)

Casper, you might have been better off if your doctors were following the new baseline-at-40 guidelines of the AUA, EAU, or NCCN, then...too bad these smarter guidelines weren't implemented until recently.  Too bad that it took the "wake-up call" of the USPSTF to motivate change...

I'm having surgery in 13 days. I'm 47.

According to the government recommendations I would not even be tested until I turned 50.
My primary physician believes in the government recommendations for PSA testing and DRE exam, so I have 3 more years right?

So how did all this come about with me being "checked" and ultimately having PC diagnosis?
My wife's workplace offers yearly health screenings, I had my PSA checked when I was 42 as an option ($40) at my wife's request at the health screening.

In 2007 it was 2.8 - The rest is history.

I'm an advocate of getting PSA tested no matter what age!

if we lived on the planet vulcan i think a convoluted, thinking man's approach to PSA screening that maximized lives and dollars saved would be the obvious solution.

but here on earth i believe in annual PSA screening beginning at age 40.  the test is a lifesaver (a PSA test saved my life).  it's what the doctors and patients do with the results that's the problem.  i am for annual testing and better education.

ed

 

I'm utterly shocked to learn that PC screening would "screen" people and possibly lead to catching cancer early. Shocked I tell you.

iSpark said...
I'm having surgery in 13 days. I'm 47.

According to the government recommendations I would not even be tested until I turned 50.
My primary physician believes in the government recommendations for PSA testing and DRE exam, so I have 3 more years right?

So how did all this come about with me being "checked" and ultimately having PC diagnosis?
My wife's workplace offers yearly health screenings, I had my PSA checked when I was 42 as an option ($40) at my wife's request at the health screening.

In 2007 it was 2.8 - The rest is history.

I'm an advocate of getting PSA tested no matter what age!

I'm very, very happy about the lucky circumstances that found your PC outside of the normal, "wait until 50" policy. If anyone has any problem getting their personal physician to have a PSA test during a routine physical, they should seek another primary doctor.

Also, people can look at the local hospitals & clinics in their areas -- I first started checking my PSA in the early 2000s by participating in the local PC screening programs in my area. Often you can get a PSA blood test and DRE for a mere total of $10. And it can save your life.

I really don't understand the silliness of the medical profession even having a debate on whether screening has any value. After all, it is NOT the test that can be referred to as overtreatment -- it is what is done with the test results that could fall into that category.

In the meantime, regular PSA testing can identify trends such as rising numbers. It is after a PSA number has spiked in comparison to the previous one(s) that more investigation is needed. And this certainly is NOT overtreating anything.

Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1.
Semi-firm erections now happening 14 months post-op & slowly getting a bit stronger.

Post Edited (HighlanderCFH) : 3/10/2013 3:52:08 PM (GMT-6)

I think there should be screening beginning at 40. It's an easy and inexpensive test. Very simple.

However, from my own experience, it wasn't the PSA test that began the wheels rolling for me, it was the DRE. I'm adopted and have always believed in allowing the Dr's to do their work because I have no family history to go from. For me, to address that blind-spot, it means come he!! or high water, getting a physical every year. I'm pretty certain I'm in the minority, at least amongst my peers, when it comes to that philosophy. Most of the people I know don't have regular checkups much less annual physicals; and their reasoning is, "...I don't feel bad and I don't want bad news..."

I think the PSA is a good tool for providing people who want information with the information they desire, generally. I think most of us here fall into that category. But to get to other people that might really be in danger and have no idea that they are, the PSA needs to be a part of the general bloodwork being done when men visit their doctors for any reason upon reaching 40. It's a piece of the puzzle, not a magical crystal ball.

Thanks walkbyfaith,
I think I'll be fine when I'm @ 3 months out post op.
It's the day of surgery and the following weeks that I'm anxious about. More so about the first week probably. :-(
The unknown is a scary place.

gedman said... I got a PSA tests at 41 as a "fluke", which found my PCa. I probably would have died before reaching the age of 50.   gedman, I cannot comment specifically about your case but I can comment about my case, and my case characteristics are very similar to your with one key measurement s smidgen better, another key measurement a smidgen worse…overall very similar.   Both of us were diagnosed with prostate cancer (PC) in our 40s, and both were very solidly INTERMEDIATE-RISK cases. Much like just about everyone else diagnosed at our age, I knew next to nothing about PC when I stumbled into the set of circumstances that led to a prostate biopsy and subsequent diagnosis.   Those first weeks— which is pretty much where you are now, still less than 2 months since diagnosis —were filled with fear, uncertainty, anxiety, worry, and concerns about my own mortality .   But perhaps unlike some others new PC patients, after the first month or so, I began to immerse myself in “patient education” which was a process that continued to be a vigorous pursuit of mine for, perhaps, the next 2-years or so.   After about the first year or so, I became knowledgeable enough to confidently start sharing what I learned with others—I had gone up the layman’s learning-curve enough to be contextually aware of what I had learned and understood from reputable sources (and I had a good idea how to tell reputable sources from the rest), but more importantly I also learned a lot about what I did not know (some of which is unknowable in the PC-world)—and that was about the time I joined and started posting on HW. One of the observations that numerous medical journal editorials are written about is the extent of the fear (along with other stressful emotions which one doctor has even gone so far as to label it as a “hysteria”) which overtakes just about every newly diagnosed cancer patient.   When one hears the words “you have cancer,” the assumption is that you are going to suffer and you are going to die prematurely.   This is a perfectly understandable reflexive fear because historically a diagnosis of many types of well-known cancers was a death sentence.   As one doctor editorialized, “ In Western society at large, the cancer ‘zeitgeist’ is that this disease is dreadful and must be caught early and treated aggressively to avoid what would otherwise be a painful and premature death .” For some other cancers, this fear is warranted—there are several well-known cancers for which mortality is poor; lung cancer and pancreatic cancer among them.   But prostate cancer is really like two, or perhaps three, very different diseases .   To be sure, there will be close to 30,000 men who will die in the US of prostate cancer this year, but these deaths will come almost entirely from the disease subset which is categorized as HIGH-RISK.   And even among HIGH-RISK patients (which is estimated to be almost 15% of all men diagnosed with PC), the disease-specific mortality is not as high as lung or pancreatic cancers.   In other words, many HIGH-RISK men die from heart disease, other cancers or other causes besides PC (overall mortality does not equal PC disease-specific mortality). At the complete opposite end of the PC-disease spectrum and in recognition of the reality that PC really is at least two, and perhaps three, different diseases, today’s most knowledgeable PC clinicians (and the NCCN) rarely recommend aggressive treatment for LOW-RISK category men.   For the most part, they recommend proactively monitoring their case (while taking steps within the patient’s control to minimize their risk of progression) in order to separate out the fraction of men who progress into the INTERMEDIATE-RISK category from those who do not…and many will never progress out of the LOW-RISK category or need treatment. Solidly in the middle of, but distinctly different from those two extremes is the INTERMEDIATE-RISK cases (where you and I reside).   Going forward, there will continue to be a lot of research into which cases in this category do and do not need treatment, but the rule for today (in the published NCCN Treatment Guidelines for Clinical Oncology ) is that  IF your life expectancy is greater than 10 years and you are diagnosed with an INTERMEDIATE-RISK case, then you should proceed with either RP or RT.   A very small percentage of men in this category will progress and eventually die of PC, but if you are young enough when diagnosed (like I was; my life expectancy was >30 years), there is a high enough probability that you will begin to suffer disease symptoms which would otherwise need a less desirable treatment…so better to treat sooner than later. The likelihood of an INTERMEDIATE-RISK man progressing to death is a small percent of a minority percent.   It is worth, at this point for completeness, to comment about one of the great unknowns in PC…that there is a rare variant of PC for which essentially no treatment is effective.   It is difficult to identify, and it does progress through each of the risk categories; but surgery, radiation and other treatments have little effect on it’s progression.   The good news is that it is very rare; the bad news is it really doesn’t matter what you do.   So, while today’s broad lexicon of all “cancers” still evoke the fear of premature death, the reality is that for INTERMEDIATE-RISK cases (like mine, and many others here at HW), that fear is NOT based on the actual natural history for the vast majority of similar PC cases, or a reality of how cases progress.   When I hear someone in this RISK category say something like, “without getting a PSA test, I would be dead in 10 years” is simply probably not true.   Remember, only about 1 in 48 men treated today actually benefits by extended life …and that man was probably a HIGH-RISK case and not an INTERMEDIATE-RISK case.   Approximately a year and a half ago, there was an interesting HW thread titled, “ Screening Saved My Life — a popular sentiment, but how true? ”   Tony, an extremely savvy PC layperson, made some interesting comments about the numbers of men who, in his observation from leading UsToo groups, felt the same as you expressed.   You aren’t alone in feeling this ( your quote at the beginning of this posting), but unless there are more relevant facts about  your case that you did not include, it's not likely to be the an accurate prediction...     Post Edited (Casey59) : 3/11/2013 2:35:06 PM (GMT-6)

I would like to be clear that I agree with you...there is NOT "zero possibility" (your phrase).  This is very well understood, and deliberately taken into consideration in this posting.  In the medical field, practicitioners deal with probabilities, not certainties...  

 

It happens that men go from a G6 at biopsy to G9 after surgery; but it also happens (with probabaly higher likelihood) that men simply die on the table from surgery.  Whats more, re-biopsy of LOW-RISK men (G6) results in an equal percentage who are down-staged as are up-staged--about 25% go up, about 25% go down, and about 50% stay the same.

 

If you have G6 at biopsy, then the best thing is to a) send your biopsy slides out for an expert second opinion, and then b) have a repeat biopsy within 12-18 months.  If your confirmational biopsy re-confirms your G6 (and your other case characteristics are LOW-RISK), it becomes not just unlikely, but extremely unlikely that you need to do anything other than modify your lifestyle habits and continue to monitor regularly.  [note:  this is not medical advice; but it is the medical advice that one would typically receive today]

 

Few things in life are certain...

Post Edited (Casey59) : 3/11/2013 3:09:12 PM (GMT-6)

F8 said...
you've got a hard sell here Casey.  maybe if you found some guys who haven't already been to hell and back.....

ed, you make a good point...one I've posted about previously.

 

For LOW-RISK men:

It is difficult to engage in conversations with low-risk men who have already had an RP because I don't want to hurt anyone's feelings.  A RP can't be undone.  The men that are post-RP, that geared up for their major surgery, and are gung ho—you can't tell them that they might have done the wrong thing, not after what it has cost them financially, emotionally, and physically.  THAT is why doctors, and the well-educated (school of hard knocks) patient support sites like HW, need to communicate more effectively with new patients up front, and strongly resist any encouragement to rush into an aggressive treatment.   While men are unwittingly rushed into a drastic operation without a full understanding of the consequences, they defend their surgeon (the one who did the rushing) with the notion that he "saved their lives," when in fact for low-risk patients the surgery probably had no impact on their longevity.

For INTERMEDIATE-RISK men:  Their aggressive treatment was appropriate (if their life expectancy was greater than 10-years), but my only point in my lengthy reply was that it is unlikely (no matter how scared you were) that you were actually going to die.

 

 

I've tried to make the point previously that PC is really two, and perhaps three, very different diseases...perhaps this statement is better understood now...

 

ed, I thought I was going to die too. But that was before my patient education. Now, the only thing I'm CERTAIN of is that I will die, but a) since I had intermediate risk PC, it probably won't be from prostate cancer, and b) since I got treated I probably will never have to deal with PC again.