Friday, August 3, 2012

The System Sometimes Works - Why a baseline PSA is important.

Here's a success story and for once i'm impressed, not only did the system work, it worked when by all rights this patient would normally have slipped through the cracks and the results probably would have ultimately proven to be fatal.

This is the main reason men should have a baseline PSA performed in their 40's.

A 53 year old patient presented with a PSA of 1.1 but has a palpable nodule in his prostate, that has been biopsied and is confirmed to be cancer.

The patient has a family history of prostate cancer, his father died from metastatic prostate cancer. His primary care physician had been performing routine (annual) PSA screenings. I'm not sure what prompted the primary care physician to follow up but this man had three good reasons for follow-up:

1. Family history, his father died from prostate cancer.
2. Rising PSA.
3. An abnormal DRE.

Normally if a 53 year old male has a PSA of 1.1, it could/would be considered normal. Most physicians still use the magic number of a PSA of 4.0 as an action level to follow-up. Even the more recent recommendations is 2.5 for men under 70 (and that's for those that even still agree to do screening PSA's).  In this man's case his PSA actually went from:

Date                PSA
Sep-08             0.6
May-09            0.6
Nov-09            0.7
Nov-10            1.4

The primary care physician repeated the PSA in May 2012 and it had dropped to 1.1 (I left it out of the graph because it confuses it) but the primary care physician performed a DRE. It indicated this was not a bad reading I personally think one should have been performed within 3 months of the first abnormal reading but... low and behold they felt a firm nodule on the prostate. The patient was referred to the Urologist who decided to perform a biopsy. Of the six cores removed, one of them was positive for Adenocarcinoma with a Gleason score of 6 (3 + 3) in 10% of the sample.

This could have gone bad at so many junctures. What if;

1. If the physician looked at the PSA only and said, 1.4 is normal, not an unreasonable decision even for  53 year old..
2. If the nodule was on part of the prostate that was not within reach of the finger.
3. If the primary care physician was not experienced enough to recognize the nodule was not normal.
4. If the biopsy had missed the tumor (it's still possible some of the other cores did miss other tumors).

Bottom line, you need to look at the whole picture. Even if the nodule(s) weren't palpable, the PSA velocity indicates there is something bad going on here. The doubling time was 1 year. Having 3 years of constant readings followed by 2 indicating an increase is a big red flag. This patient needs treatment, he is 53, the chances are good that if left untreated, the cancer will cause his demise.

GOOD WORK to all those involved.

Get a baseline PSA performed! Then annual screening (every two years might be acceptable if your young and have no family history or other contributing factors).

Tuesday, June 12, 2012

PSA Testing, I'm getting more annoyed

The more I read the USPSTF recommendations on Prostate Cancer Screening the more annoyed I get. Part of their recommendations are what "practitioners" should tell their patients. The article "Talking With Your Patients About Screening For Prostate Cancer" is for doctors and suggesting to them on how they should deal with their patients, even ones that ask about screening. I really hope there aren't any doctors that actually follow the recommendations in the document!

If you read my previous blog, you'll know I'm "flogging a dead horse" but the recommendation specifically looks at whether screening is a tool to prevent deaths. It ignores quality of life. It also assumes that a high reading that results in a negative biopsy is a false positive and results in unnecessary treatments. I'm not saying there aren't men being unnecessarily treated but I don't think it's as widespread as men that are being screened, detected and appropriately treated.

These articles quotes statistics for some things and uses vague terms or others, for example;
  • 90 percent of men with prostate cancer found by PSA choose to receive treatment. Many of these men cannot benefit from treatment because their cancer will not grow or cause health problems. 
How many constitutes many? Merriam-Webster dictionary defines many as:
  • consisting of or amounting to a large but indefinite number
I could not disagree with this statement any more. I'm yet to meet a cancer that does not grow and cause problems, unless of course you dies before it grows. Again referring to Merriam-Webster dictionary on the definition of cancer;

  • a malignant tumor of potentially unlimited growth that expands locally by invasion and systemically by metastasis.

Here's what should happen (in my opinion), and I'm assuming the worst case here.

1. You get a PSA test with a high reading (high being a relative term).
2. Repeat the PSA. If it's higher still, repeat it one more time
3. You go to your urologist, he'll decide if it's an Infection, BPH, or needs a biopsy.
4. You get a biopsy.
5. You wait a week, it comes back negative, no cancer found!

Great, I'm done. Well not yet. You need to wait 3 months and get another one. If it continues to rise you need to go back for another biopsy, it's quite possible they just missed the tumor (I will write an article on this soon), especially if the prostate cancer is early and small.

I've seen/heard of patients that have gone back 4-5 times before they finally found the cancer, his PSA kept rising though. By the time they biopsied a piece of cancerous tissue his PSA was in the 20+ range.

Use common sense, if your 90 and have heart problems your probably not going to look for a prostate cancer. If your 60 and in great health get a PSA test, in fact if you haven't had one performed earlier as a baseline, shame on you!

I'd really like to know if all the people on this task force follow these recommendations for themselves of their family members. I sure hope they don't and won't.

Friday, June 8, 2012

USPSTF Position on PSA Testing, a D?

Well obviously they did not read my last blog, I guess I really didn't expect them to! I need to Blog more frequently so it can be read and make it higher on peoples list and maybe they'll see it. I don't think it will affect their decision though.

The US Preventive Services Task Force (USPSTF) published their current recommendations on PSA screening. They gave it a "D" that means "The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." So their recommendations for practice is "Discourage the use of this service."

The Draft recommendation last October recommended that man over the age of 75 not be tested, but testing for men under the age of 75 the data was inconclusive. The final recommendation is much more damaging.

This study was generated from two main sets of data. The first is considered to as the US PLCO trial, This is the prostate, lung, colorectal and ovarian cancer trial data all rolled into one. The second is the RESPC trial from Europe, which is the European Standard Study for Screening of Prostate Cancer. The bottom line is this data specifically looks at mortality, that is how many men die from Prostate cancer. The conclusion they say from the data is 4-5 per 1000 men. According to the research quoted as part of this study, if we screen all men with a PSA Test that only decreases the number of deaths from prostate cancer by 1? If you're that one man out of every 1000, that's pretty significant. It could also mean that most men, even if they have prostate cancer, are dying from some other cause or they're list cause of death os something other than prostate cancer. Men do not typically die from prostate cancer, they might die from the complications of prostate cancer and it really depends on how that is listed on the death certificate. This relates back to how accurate the statistics are in the above mentioned studies. This is a subject of a whole different blog.

"There are three kinds of lies: lies, damned lies and statistics."
Mark Twain's Own Autobiography: The Chapters from the North American Review

Last year (2011) at a UK meeting, data was presented that showed that the death rate for men diagnosed with Prostate Cancer in the UK was almost 50% compared with 15% in the US. They attributed the large disparity to the fact that PSA screenings are not performed for asymptomatic men the UK. So their conclusions were the exact opposite.

But let's continue, let's assume their statistics are right:

To me the issue is what about quality of life? This study implies it is concerned about quality of life because it discusses the complications of the biopsy and treatment. What about the complications of not being treated? If you have an aggressive prostate cancer you will get worse complications from the disease than the treatment. It's like everything else in life, it's a risk vs benefit relationship. BUT you cannot adequate evaluate the risks and benefits if you don't have the appropriate information. The PSA test gives you an important piece of that information.

Without a PSA Test, by definition, prostate cancer cannot be found until it is at last grade of Stage 2, referred to as a T2B, almost a Stage 3. It has to be palpable (felt).

Stage IT1aN0M0G1
Stage IIT1aN0M0G2–4
T1bN0M0Any G
T1cN0M0Any G
T1N0M0Any G
T2N0M0Any G
Stage IIIT3N0M0Any G
Stage IVT4N0M0Any G
Any TN1M0Any G
Any TAny NM1Any G

The BEST case scenario, according to the Partin tables, data widely accepted to be the best authority on whether the cancer has spread outside the prostate gland) is that 12% of men already have disease outside the prostate. If you have a palpable prostate and a biopsy shows a PSA of over 4, that jumps to 29%. A lot of doctors won't even send you for a biopsy until the PSA is over 4. That means 3 out of 10 men that have a PSA over 4 and a palpable nodule will have disease outside their prostate ALREADY.

I want to get tested (and do). If it comes back high I can then decided if I want to take the risk of the biopsy, and if subsequently it's cancer, I can decide if I want to take the risks of my chosen treatment. If I wait until I am symptomatic my options have immediately decreased as will my potential life span if I'm otherwise healthy. Metastatic prostate cancer is a horrible disease, but we can control localized prostate cancer.

Have your PSA tested, then you can make an informed decision. It's a cheap test. If you can't afford it, contact a local Prostate Cancer Awareness Group of which there are thousands, some of them offer free screenings.