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PSA tests - should they be routine.

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User
Posted 23 Jul 2020 at 13:37
But then that is an issue in it's own right - some prostate cancers simply don't show up on MRI scans. John was diagnosed with an assumed T1a because his scan was clear but when they got in, they found that the cancer was present throughout the gland and into his bladder neck. Even with the more modern mpMRI, and choline / gallium / F18 / 18F there are men like CJ whose scans remain clear despite there obviously being active cancer. For true PCa screening, every man would need to be offered regular PSA and DRE with follow up mpMRI and biopsy in any circumstance where the PSA was at all elevated, the DRE was suspicious, the man was symptomatic and / or any other risk factors were present. I suspect, as suggested, the country simply cannot afford it.

My biggest worry (call me a cynic) is that we will see less diagnostic testing in the next few years, not more. COVID will almost bankrupt us as a country - I think we will see ED treatments withdrawn, projects like the innovation fund withdrawn, a stop to the roll out of SpaceOar, cancellation of the plans for two more proton centres, etc. We have seen on here the impact of the privatisation of urology services in the South West, where a group of GPs now hold the contract for all PCa diagnostics and men can go through hell just trying to get onto the books of a specialist.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 25 Jul 2020 at 13:00

I tried to read up on it a bit but it is complex. If I'm not mistaken, prostate cancer surgeons (including famous ones such as Walsh, Catalona, or d'Amico) tend to think regular PSA screening should be done routinely (eg here or here). In contrast, Richard Ablin, who is usually credited with discovering the PSA molecule, is strongly opposed to screening. Screening tends to be recommended from 45 or even 40. This young age is more to establish a baseline PSA level than to detect PCA. 

Clinical trial data on the effectiveness of screening are hard to interpret, for example, it turned out in one trial supposedly showing ineffectiveness of screening that many men in the control group had received PSA tests anyway, skewing the results against screening. 

Personally, I'm persuaded by the arguments for screening in spite of the fact that overtreatment will occur. Note that compared to breast cancer, in terms of "years of life lost", much less is to be gained screening for prostate cancer than for breast cancer, see here, here and here.

User
Posted 25 Jul 2020 at 15:28

Wicher

I’d definitely be in favour of earlier screening. Verification of prostate health can only be a good thing given the number of guys developing prostate cancer early to mid 40s. Really opened my eyes up as time from initial symptoms and elevated PSA to biopsy was 4 years. I’m lucky that I had symptoms as I would have been none the wiser with potentially a bad outcome had I not acted quickly and had treatment.

TG 

Edited by member 25 Jul 2020 at 22:04  | Reason: Not specified

User
Posted 25 Jul 2020 at 16:57
I wonder, how many cases are like mine, with the tumours at the front & not detectable with a doctor's finger - as a percentage?
User
Posted 25 Jul 2020 at 17:13
Mine wasn't detected by the finger test either. As I'd had a high PSA for some time and a previous negative biopsy, it was only a chance blood test (I was being tested primarily for bowel cancer, which was thankfully negative) that picked up that the PSA had risen significantly since the previous test.
User
Posted 25 Jul 2020 at 17:35
John had a PSA of 3.1, no symptoms, a small soft prostate and a clear MRI - thank god for the instincts of a young doctor who decided to refer him to urology anyway, and for the now vilified TRUS which managed to pluck out a cherry of G7. Post-op, the cancer was shown to be in every segment of his prostate and had invaded the bladder neck.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 25 Jul 2020 at 18:24

Originally Posted by: Online Community Member

Wicher

I’d definitely be in favour of earlier screening. Viability of prostate health can only be a good thing given the number of guys developing prostate cancer early to mid 40s. Really opened my eyes up as time from initial symptoms and elevated PSA to biopsy was 4 years. I’m lucky that I had symptoms as I would have been none the wiser with potentially a outcome had I not acted quickly and had treatment.

TG 

I agree. If you develop PCa before 50, you'll almost certainly need treatment at some point. Early screening might have saved me from SRT and possible problems further down the line. As many specialists argue and I think Barry implied, the real question is not whether to screen but how to manage treatment, ie when to do watchful waiting etc.

 

User
Posted 25 Jul 2020 at 18:58

Originally Posted by: Online Community Member
John had a PSA of 3.1, no symptoms, a small soft prostate and a clear MRI - thank god for the instincts of a young doctor who decided to refer him to urology anyway, and for the now vilified TRUS which managed to pluck out a cherry of G7. Post-op, the cancer was shown to be in every segment of his prostate and had invaded the bladder neck.

Why is TRUS villified or is that just non-targeted TRUS?

_____

Two cannibals named Ectomy and Prost, all alone on a Desert island.

Prost was the strongest, so Prost ate Ectomy.

User
Posted 25 Jul 2020 at 19:16
Just non targeted, some argue a template biopsy is the gold standard now.
User
Posted 25 Jul 2020 at 20:25
Both types made me pretty ill, so I would prefer other methods. They may exist, but not much money is being spent on them.
User
Posted 25 Jul 2020 at 20:33

Originally Posted by: Online Community Member
Both types made me pretty ill, so I would prefer other methods. They may exist, but not much money is being spent on them.

Agreed. Something non-invasive would be infinitely preferable, but as we've seen, not all tumours show up on even mpMRI. But even MRI is horribly expensive. We had one done privately on my wife's knee and it cost £500. Pretty sure my gadolinium mpMRI would have been even more. It's far too expensive for a screening test.

_____

Two cannibals named Ectomy and Prost, all alone on a Desert island.

Prost was the strongest, so Prost ate Ectomy.

User
Posted 25 Jul 2020 at 21:12

Lyn i so agree with your comment on communication to wives and partners. My wife nagged me after seeing a Bill Turnbull interview. I didn’t have any symptoms but to shut her up I had a blood test at my annual MOT. Guess what 6 months later I had no prostate - initial result PSA 13 leading to a biopsy Gleason of 3+4 and stage T2, histology after surgery Gleason of 9 and T3B grade. Marsden surgeon said I was months away from spread into lymph nodes.

And I thought I didn’t have any symptoms- thank god for my nagging wife (and Bill Turnbull). I am soooo lucky!!!

User
Posted 25 Jul 2020 at 22:16

Originally Posted by: Online Community Member

Originally Posted by: Online Community Member

 

I agree. If you develop PCa before 50, you'll almost certainly need treatment at some point. Early screening might have saved me from SRT and possible problems further down the line. As many specialists argue and I think Barry implied, the real question is not whether to screen but how to manage treatment, ie when to do watchful waiting etc.

 

About 50% of men in their 50s have some prostate cancer cells so I think it is more precise to say "if you are diagnosed with PCa before you are 50" rather than "if you develop ..."

The vast majority of men with prostate cancer will never know, or not until they are old enough to die of something else - men diagnosed in their 30s & 40s tend to have a more aggressive and persistent strain that radical treatment does not resolve. 

 

 

Edited by member 25 Jul 2020 at 22:20  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 26 Jul 2020 at 06:16

Originally Posted by: Online Community Member

Lyn i so agree with your comment on communication to wives and partners. My wife nagged me after seeing a Bill Turnbull interview. I didn’t have any symptoms but to shut her up I had a blood test at my annual MOT. Guess what 6 months later I had no prostate - initial result PSA 13 leading to a biopsy Gleason of 3+4 and stage T2, histology after surgery Gleason of 9 and T3B grade. Marsden surgeon said I was months away from spread into lymph nodes.

And I thought I didn’t have any symptoms- thank god for my nagging wife (and Bill Turnbull). I am soooo lucky!!!

As Prostate cancer, is the biggest killer of men, there should be screening, be it PSA or other methods. I would suggest, from the age of 55 - earlier, if there are symptoms. Better to catch it early, than end up like Bill, with chemotherapy wrecking your life.

Edited by member 26 Jul 2020 at 06:17  | Reason: Not specified

User
Posted 26 Jul 2020 at 08:33

Originally Posted by: Online Community Member
Mine wasn't detected by the finger test either. As I'd had a high PSA for some time and a previous negative biopsy, it was only a chance blood test (I was being tested primarily for bowel cancer, which was thankfully negative) that picked up that the PSA had risen significantly since the previous test.

Obviously a rubbish negative TRUS biopsy, I expect?

Cheers, John.

Edited by member 26 Jul 2020 at 08:38  | Reason: Not specified

User
Posted 26 Jul 2020 at 08:37

All the doctors and oncologists who specialise in PCa I have spoken to are in favour of testing.

Cheers, John.

Edited by member 26 Jul 2020 at 08:38  | Reason: Not specified

User
Posted 26 Jul 2020 at 08:44

Originally Posted by: Online Community Member

As Prostate cancer, is the biggest killer of men, there should be screening, be it PSA or other methods. I would suggest, from the age of 55 - earlier, if there are symptoms. Better to catch it early, than end up like Bill, with chemotherapy wrecking your life.

That already exists for men 50 or over. I agree with you that screening is desirable for those who want it - preferably for men >40.

The problem with trying to force screening on people is that many will not want it. You can't impose your world-view on people without the political power to do it and the economic power to pay for it.

I think also there is a real "don't drop the soap" stigma about having a finger shoved up your bum. Certainly it was very offputting to me and I was surprised how much of a non-event it actually was. My mother-in-law, mum and wife started badgering me when a year or two ago and I said "when I'm 50". In the end I only waited 3 months after turning 50. Blood test, no problem. Finger up bum - offputting.

Not only that, but the GP's DRE didn't detect anything.

Online Community Member wrote:
All the doctors and oncologists who specialise in PCa I have spoken to are in favour of testing.

Are they willing to give up their Porsches to help fund it? 😆

Edited by member 26 Jul 2020 at 08:45  | Reason: Not specified

_____

Two cannibals named Ectomy and Prost, all alone on a Desert island.

Prost was the strongest, so Prost ate Ectomy.

User
Posted 26 Jul 2020 at 09:19

Originally Posted by: Online Community Member

As Prostate cancer, is the biggest killer of men

The above premise would appear to be incorrect. 

Heart and circulatory diseases cause more than a quarter (27 per cent) of all deaths in the UK; that's nearly 170,000 deaths each year - an average of 460 people each day or one death every three minutes.

https://www.bhf.org.uk/-/media/files/research/heart-statistics/bhf-cvd-statistics-uk-factsheet.pdf 

 

  • Prostate cancer is the most commonly diagnosed cancer in the UK.

  • More than 47,500 men are diagnosed with prostate cancer every year – that's 129 men every day.

  • Every 45 minutes one man dies from prostate cancer – that's more than 11,500 men every year.

  • 1 in 8 men will be diagnosed with prostate cancer in their lifetime.


https://prostatecanceruk.org/prostate-information/about-prostate-cancer

 

So 32 men die in the UK each day of prostate cancer (11500/365)
But 226 men die each day from heart and circulatory diseases (49.3% of 460. UK population 49.3% male)

Edited by member 26 Jul 2020 at 10:38  | Reason: correcting my own calculation error

_____

Two cannibals named Ectomy and Prost, all alone on a Desert island.

Prost was the strongest, so Prost ate Ectomy.

User
Posted 26 Jul 2020 at 10:57

Originally Posted by: Online Community Member
Obviously a rubbish negative TRUS biopsy, I expect?

Not obvious at all. It was several years earlier and my PSA levels were less than half of when the biopsy was positive.

User
Posted 26 Jul 2020 at 11:15

Originally Posted by: Online Community Member
But 226 men die each day from heart and circulatory diseases (49.3% of 460. UK population 49.3% male)

There's an error in your (unwritten) assumption there - just because 49.3% of the population is male, does not mean that 49.3% of those suffering from heart and circulatory diseases are split the same way. In fact, men are slightly more likely than women to die from CVD (85,897 deaths vs 81,219 in 2018), mostly because they are much more likely to die of coronary heart disease (40,395 vs 23,737).

 
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