The Unending PSA Controversy

www.medscape.com/viewarticle/829441?src=wnl_edit_tpal&uac=206170AZ

This Medscape article suggests a database that shows likelihood a given doctor will recommend AS versus recommend treatment, and also a standard boiler plate presentation of the facts that doctors can adapt.

Also questions how many men over 65 are told there is no survival benefit at lower Gleason scores.

LupronJim

I find these threads interesting because I have a son. At this point I am just trying to get my son to eat well and live a healthy lifestyle to avoid getting cancer.

I know that the surgeon that my husband used and the urologist who diagnosed him with PCa do multiparametric MRI's before they do biopsies at this point (if insurance pays). I don't know if they do it to determine whether or not to do a biopsy, or just to determine where to stick the needles though.

John T said...
Treatment for cancer almost always involve an emotional decision rather than a rational one. Emotional decisions don't respond well to logic.
In order to change minds an emotional argument works best, not a logical one. Either changing the name of very low risk to other than "cancer" or focusing on the dreadful side effects of treatment are two ways of swaying the emotional argument.

Yes, and a teacher in marketing can also explain to you how he can get the public to buy an unhealthy product while thinking it's healthy.

Problem with your point, John, is the decision is perfectly rational for most and many, if not most, don't suffer dreadful side effects.

I sent a client to Scholz this week. Someone here knows this. It's the second person I send to Scholz. I also think Scholz has a great deal to profit personally from having people try to manipulate the emotions of those seeking treatment.

clocknut said...
I've always maintained that the PSA test is absolutely the wrong target. The problem has always seemed to me to be what occurs after the prostate test. We seldom solve a problem when we fail to identify the root cause and concentrate our efforts on events which may be associated with the problem but not the actual cause of the problem. Thanks, Yoop.

I think Clock is spot on with this post. I have always felt that the problem lies with lack of guidelines for what to do after the PSA test rather than horsing around with guidelines for when to test.

And, I also thank Yoop for sharing the original comments from Dr. Sholz. I find little to argue with and much to praise in his assessment. These MRI tests are more and more common/available and the urological community needs to get on board rather than continue the same old routine of PSA test/biopsy/treat.

And, while some may question our never ending debate on these matters, I personally see a lot of value. While the horse has left the barn for most of us here we unfortunately have a continuous stream of new members. If the regulars and veterans have a good understanding of state of the art and alternatives, we are better prepared to give meaningful advice to newbies. I can use AS as an example. In the not too distant past on this forum, AS was treated with disdain by many of us. Now, even the most ardent pro-treatment guy will usually tell a newbie with low-grade cancer to consider AS. That is progress, IMHO.

Jim

Thank you, Paul. Can you please tell that to my wife?

Jim

Davidg, I have no earthly idea what you are talking about and how it remotely relates to my post. Are you disagreeing with my agreement with Clock's post? Are you disagreeing with my thanks to Yoop for the original post? Are you disagreeing with my praise of Dr. Sholz' points? Are you disagreeing with my position that debate and discussion about these things is a good idea? Or what? I re-read my post and made zero references to advocacy, simplification of side effects, irrationality or several of the other descriptors in your post.

Whatever. You and I see things very differently but that's what makes for an interesting world.

Jim

davidg,
It may appear to be totally rational to the person making the decision. When scientists put people under an MRI and view the brain activity the emotional portion of the brain is the part that is activated, not the logical section. In making decisions such as math problems or decisions that one is not emotionally involved with, the logical portion of the brain is activated.
This is not being critical of anyone one; it's just how the human brain works.

Someone, please ask me why I don't post here much anymore. Oh wait - it's painfully obvious, isn't it?

I put something out here to help the newbies and it still turns into a pi$$ing contest - really?  David, why are you so cynical?

Yoop, out.

Yoop - I've lived in Rome, London and NYC most of my life. Wouldn't survive without cynicism. I was responding to John T's statement which seemed odd to me, not to the piece you linked. Of course I, like anyone else, like the idea of better imaging techniques. That's why I've sent two people I care for to Scholz to take advantage of these. It's shame , but they're not readily available in most parts of this country let alone the countries where my two friends come from.

  davidg said... There are many G6 men who can give you a long list of rational reasons why they sought out treatment rather than AS. In the spiriti of A Yooper's effort to help newcomers, what we can do is to make sure that a low-risk PC patient is not making a choice to pursue unnecessary treatment is out of ignorance to the fact that it may, indeed, be unnecessary. I've read (in the "Newly diagnosed") thread that HW members overwhelmingly believe that “ Overtreatment of low-risk prostate cancer is a reality you [a newcomer to HW] should be aware of .” Most newcomers won't know that.  Most newcomers are (or so they consistently tell us) in a complete state of shock.  Their emotions are running extraordinarily high.  When we read about low-risk guys asking questions like "how long to I have to live?", is that off-the-tracks-emotion, or is it an unfilled void in the early steps of their "patient education journey."  Should they be told that low-risk PC doesn't kill?  Or should they be left in an ignorance-is-bliss state (or in this case, ignorance-is-terror)? Let's keep the good information for low-risk guys, like Dr Scholz's blog comments, coming...!  Don't be dismayed, A Yooper...good job!

Yop,

The site is many things to many people .... one of the good things is the help given to newbies .... thanks to posts from guys like you.

A Yooper,
Your post is outstanding. The question as to whether imaging, of any kind, can curb the treatment trends is unanswered. Dr. Scholz makes a great point that imaging may be able to help identify aggressive versus indolent cancers but it cannot do so well enough to curb unnecessary biopsies. At least not as yet. The key use today with imaging is to help identify men after the biopsy as treatment candidates. I think most use it to verify treatment is necessary as opposed to unnecessary? By that I mean a definitive confirmation of treatment always ends in treatment. But an inconclusive scan also mostly ends in treatment as well. "I don't know that you are a safe candidate for AS so we better be safe and treat it" is the trend.

Scholz suggests that when an elevated PSA is detected that this is the time for scans as opposed to biopsies but I don't see how that trend would change. "I don't know that you don't need a biopsy so we better biopsy" would still be the trend.

Perhaps he'll touch more on it at PCRI in Los Angeles September 5-7. I look forward to this years meeting. I will be doing booth duty with Tall Allen for the PCAF website I founded. But Dr. Scholz and Maha Hussain are my target speakers at that event.

Thank you for the post. If you get a chance please look at the Richard Ablin video in the Medscape article I posted. He has a point of view that explains why I think the trends would not change through pre-biopsy imaging and post-biopsy imaging.