Harmful PSA overtesting on men with no prostate cancer symptoms

[Spielgame]

Suffering stars add to worries about prostate cancer ‘overtesting’

A study has found that asymptomatic men flock to their GPs for PSA tests — and possibly unnecessary treatment — after famous names share their stories

www.thetimes.com

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Suffering stars add to worries about prostate cancer ‘overtesting’​

A study has found that asymptomatic men flock to their GPs for PSA tests — and possibly unnecessary treatment — after famous names share their stories.

Celebrity prostate cancer awareness campaigns have contributed to harmful “overtesting” in men without symptoms, an Oxford study has found.

Researchers examined the health records of ten million men in England, looking at trends in the number of people receiving PSA tests — a blood test that can indicate prostate cancer.

Men over the age of 50 can ask their GP for a PSA test, but the tests are seen as too unreliable to be offered routinely on the NHS because they can lead to unnecessary and harmful treatments with side-effects such as incontinence and erectile dysfunction.

The new study, published in the BMJ, found that requests for prostate cancer tests from men without symptoms surged during “periods of high-profile media attention”.

Tests increased by 26 per cent in 2018 after the comedian Stephen Fry and the BBC presenter Bill Turnbull said they had been diagnosed with the disease and urged men to get PSA tests. In recent months, men have been urged to get PSA tests by famous names including Gary Lineker and the Olympic cyclist Sir Chris Hoy, who has incurable prostate cancer.

The study said that the NHS should prepare for “unpredictable surges in PSA testing, overtesting and associated costs” when celebrities publicly advocated for screening. It found that men were more likely to request tests if they were wealthy, white and from the south of the country, and “that many were tested more frequently than recommended, raising concerns about overtesting”.

However, millions of other men have not been tested at all, and the authors of the University of Oxford study said that better guidelines were needed for when and how often men should get PSA tests.

Prostate cancer is the most common cancer in the UK, with 55,300 new cases and 12,200 deaths each year. The National Screening Committee, the expert body that advises the NHS, is due to make recommendations next month as to whether to introduce a screening programme. It is expected to say that the harms of mass PSA testing outweigh the benefits.

PSA — prostate-specific antigen — is a protein whose levels can be raised in prostate cancer patients. However, the tests that measure PSA are unreliable and often miss aggressive cancers, but also lead to false positives that can lead unnecessary treatment.

In the new study, about 1.5 million patients had at least one PSA test between 2000 and 2018, resulting in 3.8 million PSA tests overall. Rates of testing increased fivefold over the study period, and many men had repeat testing more frequently than recommended.

In an editorial linked to the study, Dr Juan Franco wrote that the main concern was “that unregulated PSA testing will result in large costs and harms and increase the incidence of prostate cancer likely to remain undetected, while doing little to identify prostate cancer most likely to cause symptoms and death”.

Under NHS guidelines, all men aged over 50 can ask their GP for a PSA test even if they do not have symptoms and black men, who are at higher risk, can ask for one from the age of 45. Prostate cancer charities are calling for these guidelines to be overhauled so the tests are proactively offered to men at highest risk, as part of a targeted screening programme.

Amy Rylance, assistant director of health improvement at Prostate Cancer UK, said: “This BMJ study provides yet more evidence that major inequalities in PSA testing and confusing guidance make it difficult for men and their GPs to know how to test for prostate cancer.

“Despite this, many men are still having tests — but they’re having them unequally. Some are tested more often than necessary, while others aren’t tested until it’s too late.

“The key finding of this study is that men in the affluent south are being tested more often. But this needs to be looked at in the context of other research that shows men in affluent areas are also more likely to be diagnosed early, before their cancer has spread.

“That’s why we’ve been calling for the government to urgently update current guidelines, which are dangerously outdated and continue to cause confusion for men and their clinicians.”

Naser Turabi, Cancer Research UK’s director of evidence, said: “Prostate cancer is the second leading cause of cancer death in men in the UK, taking around 12,200 lives a year. While we’ve seen breakthroughs in treatment, more research is needed to improve how we diagnose the disease.

“As this study shows, detecting aggressive forms of prostate cancer is complex, and the current PSA test isn’t reliable enough.”

 

[LuckyR]

My urologist buddy gets em, so I get em.

 

[not_too_shabby]

Coming from myself who has had a number of scares due to unusually high PSA for my age, the crux of the issue is PSA without prostate size can cause major anxiety and unnecessary tests.

The issue with PSA is it does not tell you your prostate size. Two guys could have a PSA of 3, one has a PSA of 3 because he has a large prostate. The other guy has a small prostate, but has a PSA of 3 could have cancer. A guy with a PSA of 10 might have an infection, or cancer. It isn't conclusive without other tests.

Also be aware that strenuous exercise, sex, bike riding can also elevate the PSA. Anything that puts pressure on the prostate can elevate your PSA temporarily.

 

[LuckyR]

Coming from myself who has had a number of scares due to unusually high PSA for my age, the crux of the issue is PSA without prostate size can cause major anxiety and unnecessary tests.

The issue with PSA is it does not tell you your prostate size. Two guys could have a PSA of 3, one has a PSA of 3 because he has a large prostate. The other guy has a small prostate, but has a PSA of 3 could have cancer. A guy with a PSA of 10 might have an infection, or cancer. It isn't conclusive without other tests.

Also be aware that strenuous exercise, sex, bike riding can also elevate the PSA. Anything that puts pressure on the prostate can elevate your PSA temporarily.

Which is fine since it's a screening test, not a diagnostic test.

 

[not_too_shabby]

Which is fine since it's a screening test, not a diagnostic test.

You might think that until you have had an unnecessary biopsy. In my case, my PSA was 3, which is high for a 45 year old. The reason that I went to see the urologist is because I was having difficulty urinating. Instead of suggesting an MRI, he immediately advised a biopsy. This is riduclous for 2 reasons. First, prostate cancer rarely causing urinary issues until it is very advanced. In which case my PSA would be higher than 3. Second, a prostate biopsy would cause inflammation in my prostate which would make my urinary issues worse. I pushed for an MRI, and it showed no cancer and a large prostate which then explained the high PSA(PSA density = PSA/Prostate size) and urinary issues. Many urologist don't have your best interest in mind. They don't get paid for referring you for an MRI and they have to CTA if your PSA is abnormal. If anyone is reading this and has a PSA in the grey area, get an MRI. It will then allow you to get a PSA density value which may in fact by in the normal range, or if you do have any suspicious areas on your MRI, it will tell the doctor where to biopsy.

 

[LuckyR]

You might think that until you have had an unnecessary biopsy. In my case, my PSA was 3, which is high for a 45 year old. The reason that I went to see the urologist is because I was having difficulty urinating. Instead of suggesting an MRI, he immediately advised a biopsy. This is riduclous for 2 reasons. First, prostate cancer rarely causing urinary issues until it is very advanced. In which case my PSA would be higher than 3. Second, a prostate biopsy would cause inflammation in my prostate which would make my urinary issues worse. I pushed for an MRI, and it showed no cancer and a large prostate which then explained the high PSA(PSA density = PSA/Prostate size) and urinary issues. Many urologist don't have your best interest in mind. They don't get paid for referring you for an MRI and they have to CTA if your PSA is abnormal. If anyone is reading this and has a PSA in the grey area, get an MRI. It will then allow you to get a PSA density value which may in fact by in the normal range, or if you do have any suspicious areas on your MRI, it will tell the doctor where to biopsy.

Your commentary, even if 100% accurate (and since neither one of us is a urologist, let's not go there), supports my point. Namely, that a screening test's job is to figure out who is high enough risk to deserve a diagnostic test, which goes with your experience. Your opinion on whether this or that diagnostic test is better is a separate issue.

 

[Connor35]

Here is a reasonable article on it. Basically you need to give 500 men a PSA test in order to save one life. Testing had a 0.2% effect on prostate cancer mortality - and that's over 23 years!
And we know that biopsies, over treatment, etc have deleterious qualify of life impacts.

I think it's fine if you choose to do it -- but it's 100% fine if you choose not to.

I am 50-years-old, and I do health research for a living, and I told my doc not to do a PSA test when I turned 50. But I don't think there is a clear 'right' answer here.

The PSA Screening Test and Humility

NEJM publishes 23 year results of the European Randomized Study of Screening for Prostate Cancer trial. Only one word comes to mind: humility

www.sensible-med.com

 

[Injured Again]

I was scheduled for a biopsy. It subsequently turned out to be an unnecessary one that I refused, and I've also switched urologists due to that.

My PSA has been steadily rising for the past several years and now is slightly elevated over normal levels. At my physical last year, my primary care doctor (who is great) suggested I might consider a urologist, because I'm healthy and active, and seem very willing to make sure everything I can control is taken care of. I did so, and at the meeting he ran a model using my personal health inputs and determined my risk at prostate cancer at something like 5%, and something like 25% over the next 10-20 years. Still, he said it couldn't hurt to do a contrast MRI to see if anything is brewing, and if something is found then we can do a biopsy.

The MRI came back with no abnormal findings, but he recommended a biopsy anyway. At that time, I hadn't looked closely at the MRI interpretations so I scheduled the biopsy. A week or so out, I was looking at the MRI and saw that the interpretation was there were no localized areas of concern. I went back to the notes I jotted down from the urologist and he said he would only recommend a biopsy if the MRI found SOMETHING. So I pushed back, and ultimate canceled the biopsy.

I've since talked to a number of guys who are also dealing with elevated PSA levels and in some instances have had their prostates removed. A few of them were also recommended to have biopsies, and in one case a guy had three or four biopsies, one per year, and they found nothing because his initial MRI also said there was no localized areas of concern. So it seems they just go in there and poke around, get something like 12-15 random samples, and if they find nothing, they poke around at a different area. It's really not possible to cover the entire prostate via this random sampling without a half dozen biopsies. And the reason this guy no longer is getting biopsies is because he got E Coli from the last one and was hospitalized for over a week. He has since realized that ALL of his biopsies were done without any real cause other than possibly to help his urologist with paying for a second home.

My experience made me lose confidence in the care I was receiving from my first urologist. Prostate cancer is slow growing in most cases, and aggressive prostate cancer will result in a big spike in PSA levels. The risk of complications from biopsies is significant, including secondary infection, rectal bleeding, and blood in the semen. Not worth it from everything I can tell unless PSA levels are really high and a contrast MRI shows an area of concern.

 

[Better_Call_Raul]

What about people waiting for prostate cancer treatment that do not have friends in the White House? What should they do?
The healthcare system is broken...
Mel Gibson says drugs that might work are not promoted if there is no profit in it.

https://twitter.com/x/status/1984915690634252352

https://twitter.com/x/status/1877545575098261801

 

[drak]

There are a few relatively knew prostate cancer tests using blood or urine that are as accurate or moreso than a biopsy.

A New Blood-Based Epigenetic Diagnostic Biomarker Test (EpiSwitch®® NST) with High Sensitivity and Positive Predictive Value for Colorectal Cancer and Precancerous Polyps - PMC

In this retrospective (with partial prospective collection) case–control pilot study, we have used full blood samples from patients with colorectal cancer (CRC), patients with colorectal polyps, and patients with a ‘clear’ colonoscopy, and performed ...

pmc.ncbi.nlm.nih.gov

New urine test may help some men with elevated PSA avoid biopsy - Harvard Health

When a PSA test produces an abnormal result, the next step is usually a prostate biopsy, but these have drawbacks. Researchers are exploring strategies to avoid unnecessary biopsies, and a t...

www.health.harvard.edu

 

[onehandbh]

What about people waiting for prostate cancer treatment that do not have friends in the White House? What should they do?
The healthcare system is broken...
Mel Gibson says drugs that might work are not promoted if there is no profit in it.

https://twitter.com/x/status/1877545575098261801

T-Rump should hire Rogan and Gibson to open the T-Rump school of medicine.

 

[dannyslicer]

Here is a reasonable article on it. Basically you need to give 500 men a PSA test in order to save one life. Testing had a 0.2% effect on prostate cancer mortality - and that's over 23 years!
And we know that biopsies, over treatment, etc have deleterious qualify of life impacts.

I think it's fine if you choose to do it -- but it's 100% fine if you choose not to.

I am 50-years-old, and I do health research for a living, and I told my doc not to do a PSA test when I turned 50. But I don't think there is a clear 'right' answer here.

The PSA Screening Test and Humility

NEJM publishes 23 year results of the European Randomized Study of Screening for Prostate Cancer trial. Only one word comes to mind: humility

www.sensible-med.com

Why not get the PSA, and then skip the biopsy (and get MRI instead, if high PSA)
Seems like PSA is cheap and low impact.

 

[Connor35]

Why not get the PSA, and then skip the biopsy (and get MRI instead, if high PSA)
Seems like PSA is cheap and low impact.

I think the big question is the mental anquish worth it, not to mention all the testing one might do only to confirm that PSA was a false positive.

 

[LuckyR]

I think the big question is the mental anquish worth it, not to mention all the testing one might do only to confirm that PSA was a false positive.

Any discussion of false positives needs to also consider the mental anguish of showing up with advanced disease having not screened in the past.

 

[Connor35]

Any discussion of false positives needs to also consider the mental anguish of showing up with advanced disease having not screened in the past.

That’s fair. But that number of would-have-been-positives-if-tested is much much smaller than the number of false positives from testing. We know that there is definitely a fair bit of impotence and incontinence due to over treatment.

We all have our own utility functions and the test is available for anyone who wants it.

 

[LuckyR]

That’s fair. But that number of would-have-been-positives-if-tested is much much smaller than the number of false positives from testing. We know that there is definitely a fair bit of impotence and incontinence due to over treatment.

We all have our own utility functions and the test is available for anyone who wants it.

True, but it's impact is much, much greater. Bottom line, no one knows the future, but in my experience regretting decisions made affects folks more than just having bad luck.

 

[Soul]

That was a concern that the discover of PDA had. Professor Richard Ablin wrote a book on it ~

The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster​

The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster: Ablin, Richard J., Piana, Ronald: 9781137278746: Amazon.com: Books

The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster [Ablin, Richard J., Piana, Ronald] on Amazon.com. *FREE* shipping on qualifying offers. The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster

www.amazon.com

Every year, more than a million men undergo painful needle biopsies for prostate cancer, and upward of 100,000 have radical prostatectomies, resulting in incontinence and impotence. But the shocking fact is that most of these men would never have died from this common form of cancer, which frequently grows so slowly that it never even leaves the prostate. How did we get to a point where so many unnecessary tests and surgeries are being done? In The Great Prostate Hoax, Richard J. Ablin exposes how a discovery he made in 1970, the prostate-specific antigen (PSA), was co-opted by the pharmaceutical industry into a multibillion-dollar business. He shows how his discovery of PSA was never meant to be used for screening prostate cancer, and yet nonetheless the test was patented and eventurally approved by the FDA in 1994. Now, doctors and victims are beginning to speak out about the harm of the test, and beginning to search for a true prostate cancer-specific marker.

 

[LuckyR]

Patented in 1994, eh? Back when the death rate from prostate CA was roughly double that in 2015 in Black men (the highest risk group). I'm thinking it's a benefit.

 

[Connor35]

Patented in 1994, eh? Back when the death rate from prostate CA was roughly double that in 2015 in Black men (the highest risk group). I'm thinking it's a benefit.

Do you realize that huge peak on 1994 is due to PSA not due to cancer right?

There’s a smooth curve with a sharp peak. That peak is because men who’d have been diagnosed later - or never - were all diagnosed in 1994.

The down curve in mortality is largely due to improvements in treatments.
Look at any other cancer in the last 30,years too. It’s similar.

 

[LuckyR]

Do you realize that huge peak on 1994 is due to PSA not due to cancer right?

There’s a smooth curve with a sharp peak. That peak is because men who’d have been diagnosed later - or never - were all diagnosed in 1994.

The down curve in mortality is largely due to improvements in treatments.
Look at any other cancer in the last 30,years too. It’s similar.

Several things. First there is a smooth increase in the mortality from prostate cancer that starts before PSA was invented, through the time it was a rarely used research tool, through when it wasn't used for screening (rather for following already diagnosed cases). There is no sudden bump. Secondly, using PSA for screening would logically cause an increase in diagnoses, but please explain your theory how finding cases earlier (through screening) would lead to higher mortality. You're acting like advanced stage, lethal prostate cancer was difficult to diagnose before PSA. Not true. Remember I'm talking death rate, not diagnosing meaningless early stage cases (what this thread has been criticizing, which is reasonable).

 

[Injured Again]

I have another friend who is in his later 60’s. He was diagnosed with prostate cancer and had a non-invasive treatment of some sort that sounds like radio frequency ablation. His PSA levels were near zero for a couple of years, then spiked to 11. He had an MRI and found that the cancer has metastasized to his upper lumbar/lower thoracic vertebrae region, which apparently is not an uncommon occurrence. If nothing else, this seems like a good reason to continue PSA testing because he had no symptoms and there’s no knowing how much the spinal cancer would have progressed before he noticed it.

 

[Connor35]

I have another friend who is in his later 60’s. He was diagnosed with prostate cancer and had a non-invasive treatment of some sort that sounds like radio frequency ablation. His PSA levels were near zero for a couple of years, then spiked to 11. He had an MRI and found that the cancer has metastasized to his upper lumbar/lower thoracic vertebrae region, which apparently is not an uncommon occurrence. If nothing else, this seems like a good reason to continue PSA testing because he had no symptoms and there’s no knowing how much the spinal cancer would have progressed before he noticed it.

This is called surveillance. Not screening. PSA should definitely be used in this circumstance (and is).

 

[Connor35]

Several things. First there is a smooth increase in the mortality from prostate cancer that starts before PSA was invented, through the time it was a rarely used research tool, through when it wasn't used for screening (rather for following already diagnosed cases). There is no sudden bump. Secondly, using PSA for screening would logically cause an increase in diagnoses, but please explain your theory how finding cases earlier (through screening) would lead to higher mortality. You're acting like advanced stage, lethal prostate cancer was difficult to diagnose before PSA. Not true. Remember I'm talking death rate, not diagnosing meaningless early stage cases (what this thread has been criticizing, which is reasonable).

The best trial shows that you have to screen 1000 men for 10 years to save one life. That’s a tiny part of the mortality decrease in this plot when apply that to the Y-axis.

But as I’ve said 4 times. Do what you want. I’m not arguing no one should screen.

I’m stating that the benefits - and they do exist - are extremely small but there are also measurable quality of life drawbacks.

You sound like the type who should get screened. But to say everyone should isn’t fair as many medical bodies have concluded.