All Routine PSA Tests For Prostate Cancer Should End, Task Force Says

[bemildred]

There they go again — those 17 federally appointed experts at the U.S. Preventive Services Task Force are telling American doctors and patients to stop routinely doing lifesaving tests.

Or at least that's the way some people look at the task force's latest guidelines on prostate cancer screening, which say doctors should stop doing routine PSA tests on men of any age. (The task force earlier recommended an end to testing of men over 75.)

The American Urological Association pronounced itself "outraged" at the task force edict.

"It really is too extreme for them to say that all PSA testing should stop," fumes Dr. William Catalona, a Northwestern University urologist and PSA testing pioneer. "If all PSA screening were to stop, there would be thousands of men who would unnecessarily suffer and die from prostate cancer."

http://www.wbur.org/npr/153234671/all-routine-psa-tests-for-prostate-cancer-should-end-task-force-says

[hlthe2b]

1. I predicted this would be the case about 15 years ago...

PSA is such a problematic screening test.... But, I'm not surprised at the reactions. Once there is a perception that the test is an effective preventive life-saving screening test, it is hard to move away from it.

[skepticscott]

2. If PSA screening were to stop

the overall effect would be positive, given the much larger number of men who suffer serious consequences from treatments that are precipitated by a "positive" result, but which may not be necessary.

[unc70]

14. Strongly disagree

See my other posts. I have posted previously at DU about the serious flaws in the studies of PSA screening.

[unc70]

3. I strongly support PSA screening, particularly with folate crisis coming

The PSA is a relatively poor diagnostic tool, but it is the only readily available one for prostate cancer. Prostate biopsies are poor quality, too. Biopsies have over a 30% false negative rate, many of those at Stage 3.

BUT, complacency is a really bad idea right now, particularly with the folate crisis about to hit. Folates? Crisis? Yes, folic acid supplements greatly increase the risk of developing prostate cancer. That data is from the "aspirin" study, long-term data using double-blind placebo design.

Over the last 10-15 years, we have been enriching flour and grains with folates in a successful effort to reduce many types of birth defects. While younger women benefit from this effort, older men do not. Expect to see a dramatic increase in prostate cancer among Boomers.

I have posted about this repeatedly here at DU with details of the studies, etc.

[skepticscott]

4. The real problem

is the overreaction to a spike in PSA, and the rush to extreme treatment measures at early signs of a problem. That's what has, ironically, made not being tested and not knowing if you have a problem healthier on average.

Testing certainly doesn't have to be done every year for everyone starting at 50, though closer monitoring for those with a patrilineal history of prostate cancer is prudent. If a PSA spike is detected, closer and more frequent monitoring is warranted, but rushing to radiation treatment or removal at that point is not usually wise. Prostate cancer tends to be slow to progress and non-aggressive. Most men who get it will die of something else first, even if it is not treated.

[unc70]

7. No testing means no monitoring

I know of no one who has rushed to surgery or radiation simply based on elevated PSA. The typical responses are:

1. A month of Cipro, then retest. If still elevated, a second month and retest.

2. If PSA is still high, probably do a biopsy. Depends on age, other health issues, family history, how high PSA spiked.

If no biopsy or nothing detected in it, then retest PSA more frequently at first, probably in 3 months, then in 6, then in 12 assuming no new spikes.

3. Only when something is actually found do I know of anyone undergoing surgery or radiation. That includes those with lots of family history, though they generally are more aggressive in getting treatment.

If we don't do routine screening, then we don't have a baseline. And we get complacent. And now with the folate issue is the wrong time to be complacent.

I have friends in their 50's and early 60's who spiked their PSA and chose to just wait. One already lost his bet. Prostate cancer confined to the prostate has a high "cure" rate, but once it escapes it is really bad to deal with.

I repeatedly spiked my PSA for nearly 15 years beginning in my 40's. Had a negative biopsy early on, another years later. Four years ago, spiked again and stayed high after Cipro. This time, a positive biopsy.

I had successful surgery, but just barely in time. It was starting to grow outside the prostate, but had not spread elsewhere.

Many cases of prostate cancer are detected during surgeries for problems with urination, not from PSA screening.

[phylny]

9. Thank you for sharing your story, and I agree with your sentiments.

My husband had no symptoms - no problem with urination, no sexual dysfunction, no nuthin'. A routine PSA found that it had elevated, and long story short, he had a radical prostatectomy due to an aggressive, deadly cancer contained in his prostate. The doctor said if he hadn't acted when he did, he'd be dead in two years.

I'm glad yours was found in time, and I appreciate that my husbands was, too!

[unc70]

13. Thank you. It is important we speak out.

Glad for you and your husband. I don't know that I would have been dead that quickly, but I would certainly have been facing a serious regime of chemo or radiation if I had waited much longer than I did. Still might not have made it five years.

I think it is really important that we speak openly about prostate cancer. Most men really want some straight answers and mostly aren't getting it. I think the worry about possible side effects from surgery or other treatments, particularly sexual dysfunction, is so strong that the idea of men getting treatment they don't need is simply ludicrous. If anything, most men are too reluctant in getting proper treatment.

I have added a couple of more posts regarding fundamental problems with the research about screening.

[cbayer]

5. Good, this is exactly what needs to happen.

And I am not surprised at the AUA's response, as this is their bread and butter.

[bemildred]

6. Yep. nt

[unc70]

10. As I posted, I strongly disagree

Read my post, the follow ups, and maybe about the folic acid research.

[bemildred]

15. I have done that, and considered what you say, and I still think you are wrong.

The argument is not that nobody will be saved by surveillance, the argument is that many more will be harmed by it, not to mention the expense. I have lost one parent and two younger siblings to cancer, and have another with a positive prostate diagnosis, and I can still assure you that you won't get me near any of that "treatment" unless it appears much more efficacious than what I have seen with them. But I'm glad it worked out well for you.

[unc70]

16. This is a case where early intervention works

This is not one where treatment buys you and extra 2-3 unpleasant months. This decision is more like going from 5 years, 2 of them with the pain of bone cancer. to an alternative of 15-20 years and dying from something else.

Which treatment to choose depends a lot on age; what to do at 80 is different than at 60.

[bemildred]

18. Sometimes. nt

[hedgehog]

8. Do we have any tests (including biopsy) that can differentiate

between slow growing prostate tumors that men die with and fast growing, aggressive tumors that men die from?

[unc70]

11. Not really, not yet

There is some research looking for genetic factors, protein or other distinctive markers that can help with detection and treatment selection for different types if prostate cancers.

Considering that prostate cancer is second only to lung cancer for number of deaths for men, the amount and the quality of the research on prostate cancer is surprisingly low. Even the statistics are misleading, particularly those driving the current recommendation.

In the US, 1 in 6 men are diagnosed with prostate cancer. For comparison, 1 in 8 women are diagnosed with breast cancer. Since prostate cancers are more likely to remain contained within the prostate for some years with low probability at first of spreading, this distorts making decisions based on 5-year survival rates.

Before early detection through PSA screening, survival rates were low -- typically 20% 5-year. It was too late, already spreading to bones, painful and horrible.

Policy makers often cite age when detected and 5-year survival rates to justify "they will die from something else" (the WITH vs FROM discussion). Unfortunately, the major studies they base this upon are fatally flawed.

The study most cited to compare outcomes with and without routine PSA screening actually compared no such thing. It compared a group receiving annual PSA screening with a so-called control group who were screened based on current practice and their own decisions. This group received high levels of PSA screening comparable or slightly higher than current practice in the US!!

There is some promising research, but it is years from being available as diagnostics or as treatments.

[unc70]

12. About biopsy, there is research

A prostate biopsy (usually 12 samples) can give a lot of information and help determine the best course of treatment for a given patient. But it has limits. We know far less about types of prostate cancers than we do for many others like breast cancer.

Johns Hopkins has been studying watchful waiting following biopsy for patients with certain characteristics considered lower risk. It is too early to be sure about outcomes. This is not the same as not screening.

Another study showed that significantly better 10-year survival rates for those with surgery.

Since PSA screening is only been around for about 20 years and nerve conserving surgery became widely available even later, things are quite the muddle.

[hedgehog]

17. Thank you for that info - My husband had the nerve conserving surgery

and is doing well, but it would be dreadful to find out that he didn't have to go through that. As it happens - his cancer was found by a very anal urologist who did a thorough exam when my husband saw him fro something totally unrelated. My husband's GP had been checking his PSA annually, so either the PSA didn't go up or it went up rapidly after the annual test as the tumors grew.

[unc70]

19. Post op pathology report is best guide

It is really difficult to have an opinion without all the information. I know of cases that had already spread where the PSA never got above 2.0. Others with low PSA where the tumors could be felt "digitally".

In my case, no indication except elevated PSA until the positive biopsy. My urologist did the biopsy and saw nothing on the ultrasound guiding him. I was high II preop, stage III postoperative and growing out of prostate and starting to invade a nerve bundle.

I would encourage anyone facing this cancer to get a second opinion if you get a positive biopsy. I am lucky that I had the options of UNC and Duke.