UK study of PC screening

Yea that stuff drives me crazy...especially considering the number of us I see here in their early and mid 40's...my screening was certainly neither unnecessary or harmful. I'm grateful for my primary care doc to just happen to test me when he did.

Wow I did not find the test unnecessary at all. I had been getting it done since my forties. In Canada we pay for the test to which I have no issues with. I had no symptoms either but PSA was extremely high.

BillyBob@388 said...
But how is it that lives have not also been saved?

It's really quite simple: total deaths went down, but that change is attributable to improvements in treatments and not to PSA screening.

There is widespread misunderstanding about what the word "screening" means. It means that the entire population of men 50-69 get a PSA test. This is the policy that nearly everyone (AUA, ASCO, ASTRO, NCCN, etc.) rejects. I would also point out that a very high percentage (85%) of men who had PSAs over 3.0 went on to have a biopsy. I believe that if they had made an attempt to rule out benign causes, that would be much lower.

The results show why PSA screening is such a bad idea. It makes no difference in cancer detection or survival, and diagnoses excessive numbers of men with insignificant, low risk PC that might never require treatment. But at the same time increases their anxiety and causes rash decisions about treatment. PSA is not the test that should ever be used for population-based screening.

I’m biased because I believe an earlier diagnosis would have led to a better outcome for me, but it’s just super hard for me to believe that screening doesn’t save lives. But if that’s what the numbers say, that’s what they say.

BTW NKinney, there is no way you could possibly know that earlier treatment wouldn’t have improved the outcome for myself, or anyone else.

Post Edited (mattamx) : 3/7/2018 8:14:32 PM (GMT-7)

NKinney said...

BillyBob@388 said...

Personally, I wish I had started treatment 5 years earlier than I did. And I probably would have if I had not been so stubborn about ignoring rising PSA.

And at the end of the day what would you have had to show for it? Five more years of treatment, and that’s about all.

“Lead time”

Most likely, I would have had the same amount of treatment that I have already had, i.e. RP. But it might have occurred 5 year earlier, before SV involvement and positive margins. Or, possibly, with a lower(but still over 4) PSA, a smaller or even non detectable nodule upon DRE, and maybe Bx results not quite so ominous(but still bad enough for treatment), maybe my surgeon would have felt he could spared me one nerve instead of cutting wide all around. And quite possibly, despite not cutting quite so wide thus maybe leving me with less severe SEs, I would have come out of surgery without the positive margin and SV invasion. Or, best of all, maybe with less ominous results, maybe I would have had the wherewithal and courage to do what I should have done in the first place, RT.

Also, what with the big scare it gave me, I would have started my research on non traditional approaches- dietary, supplemental and that might even be helpful, we don't know yet. But whatever I've been doing that has so far MAYBE helped to put off BCR to at least 4 years(checked again in a few weeks) from what should not have surprised me if it had happened at 1 or 2 years. Since even my surgeon told me I had only at best a 50% chance of no BCR, and he seemed to indicate it might well be sooner rather than later. But helpful or not, I would have started all of that 5 years earlier.

So, seems to me I would have been better off knowing about this and taking action 5 years sooner, just as I feel I have been better off not finding out about it 5 years later. Are you actually saying otherwise?

And, are you of the opinion that early diagnoses is of no benefit compared to later diagnosis, probably after PC has escaped the capsule and possibly even after mets are detectable? It sounds like it, but maybe I am misreading you?

And may I ask again: do you know of a study that proves that the 50+% reduction in PC death rate that began with wide spread PSA testing and early detection in 1992 is mostly from improved treatment, and none or very little from early detection?

Some people sound just like JackH.

A sample of one, me.

If I had been screened earlier, an RP would have been curative.

I have friends who have made major investment of energy in very strong quality of aging using data from the major aging research centers in the US. Along with that approach they do not take PSA or similar tests even though they are close to 70 . It is an interesting approach.

I do understand the large population overview where psa screening does not seem justified given the small difference in mortality from this large macro perspective, even though there is lots of misunderstanding in the various analyses. On the immediate level, PSA seems very important as a signal, and each choice and opportunity along the way seems like it makes a world of difference. It would be nice if there were more linkage between the macro level and the immediate level.

I am so aware of the big business aspect of health. I call it the Health Military Industrial Complex which has replaced the "Military Industrial Complex" concept of the 1960s. When I got my first PSA test and I went to urology and they were going to immediately take the 12 cores, I had researched a bit and found something reporting Side Effects to the taking of cores. I decided to decline. The nurse practitioner explained to me that 12 cores was the "gold standard" for treatment with my psa (11.2). I tried to explain that the "gold standard" generally was exactly what I did not want to follow in medicine given how the overall system (Health Military Industrial Complex) was so driven by cutthroat capitalism.

Later I learned about the billion dollar race in the pharmaceutical industry to come up with a better test than PSA. I learned that the efforts to date, had failed to replace PSA which was a $5 test at the time. Then the PSA test became a hero to me in retarding higher cost tests. There are some analyses of Robotic Assisted Radical Prostatectomy that it has not significantly improved outcomes (trifecta of avoiding biochemical failure, preserving continence, preserving potency) though it has made for less loss of blood and faster recovery, neither of which justify the major additional cost. (still a debate here)

After two fusion biopsies, one transrectal where I was fully awake with M.D.s-in-training who seemed to make a mistake (yikes) and one transperinial with anesthesia, I wanted to go back to that nurse doing hundred of 12 core biopsies every year, and have her do it. Our perpectives change with further knowledge.

My point is that we all have our set we come in with, some of which is in error. And there are many steps in correcting those errors of understanding. I appreciate this list in helping clarify those errors. Manticore

That's a lot of blah, blah, blah.

It's not important what I think. Read the darned link in the OP...your answer is (still) right there.

It's time to move on. This feels like I'm having a conversation with a fence post.

Post Edited (NKinney) : 3/10/2018 6:05:54 AM (GMT-7)

Gemlin said...
They misinterpret the result. The study wasn't about a real screening since they only took a single one time PSA test! A real screening program means repeated sampling.

They included more than 400,000 men from Britain. Half received an invitation to have ONE TIME PSA test and the other half (control group) had no PSA test. Only 36% of the men that got the invitation did take the test!

The findings do not support single PSA testing for population-based screening.

Effect of a Low-Intensity PSA-Based Screening Intervention on Prostate Cancer Mortality
The CAP Randomized Clinical Trial

Hey, WTH, I am just seeing your point, Gemlin. One lousy PSA? And based on that a very small additional # ended up being Dx'ed with PC(4.6%) over the next 10 years as opposed to the men who were not in the original PSA group(3.6%)? (were they all diagnosed at the time of the one PSA, or later after symptoms?)

Well, how did any of them end up Dx'ed? Were there additional PSAs? Apparently not. So, did they end up with guys in both groups who were later diagnosed only when they got symptoms? I'm starting to suspect this is one of the studies designed to fail, i.e. fail to show a benefit, like Vitamin D studies that rather than comparing against a placebo, compare against an already plenty adequate dose where most of the benefit may have already been obtained? Something stinks.

So, is this right, they only took ONE PSA and then 10 years later checked to see how many were dead from PC in each group? Well isn't it at least possible that while there a small # diagnosed with what was probably on average low risk PC in the PSA group at the time of the PSA, that both groups had an equal # of men who LATER developed high risk PC, which went without being diagnosed for 10 years until it killed about the same # in both groups?

Good grief, as I am always saying, you really have to watch your studies for bias and being designed to give a probable result. I can't believe that based on such flimsy evidence they would make such a bold statement. I wonder why they didn't go ahead and do a more thorough study like following DREs and PSA trends over that 10 year period? Although, the declared result it is accurate as far as it goes, I'm just not sure it is very useful info.

Somebody said...
Among practices randomized to a single PSA screening intervention vs standard practice without screening, there was no significant difference in prostate cancer mortality after a median follow-up of 10 years but the detection of low-risk prostate cancer cases increased. Although longer-term follow-up is under way, the findings do not support single PSA testing for population-based screening.

I almost feel like saying "well, duh". So they are telling me that 1 single PSA failed to diagnose a roughly equal # of men(compared with zero PSA group) who turned out to harbor PCs that ended up killing them? That does not strike me as all that unexpected. If I had only gone by 1 PSA (1 point something) that I had 10 years previous to my diagnoses(PSA 10.9), I would not have been diagnosed until I had obvious symptoms.(and I should have had the biopsy when I hit 4.1, which would have diagnosed me several years earlier!) Wouldn't that put me in the same dang boat as the guy who never had any PSA to start with and was not diagnosed until he had obvious symptoms? Both in a sinking boat I might add? The only way PSA led most of us to a diagnoses - and hopefully even for us very high risk guys a diagnoses before symptoms- is by way of watching the trend of a rising PSA over several years. It appears that neither group in this study had the advantage of that. Hence, an almost equal % died of PC.

You don't suppose this is a study designed by folks who do not want to pay for screening NOR do they want to pay for possible lifetime of cancer treatments? Probably not, I am maybe being too cynical. But it sure seems it could have been a lot better study giving us a lot more useful info. I will say this: they have given strong evidence that if you do only one PSA and then check PC death rates 10 years later, it is not going to be of much use.

Post Edited (BillyBob@388) : 3/11/2018 7:30:14 PM (GMT-6)

Skypilot56 said...
Billy I understand your frustration with a certain individual here. It's kinda strange I have asked many times if any body has ever seen his signature? Can't believe that someone who as experienced this disease can be so critical of others. I think we have to be very careful of how we interpret all these studies. I don't believe there is anything wrong with guys getting screening. It's what happens afterwards is where the trouble starts. I for one will have to agree with you that most of the time earlier detection in intermediate and higher risk patients would absolutely have been better could have changed treatment options and possibly the outcome. If one doesn't believe that Then why are they on here and why have they had some sort of procedure done since they could have just lived with PCA and had the same results? I was with a lot of gentlemen down at the hope lodge with PCA that had metastasized and every one of them i talked to all said the same thing " Wished we would have found it earlier!" Of course maybe it was just a lot of blah,blah,blah

Larry

Thank you, Larry, for what seems to be a rational approach. I also am not expecting many to argue in favor of later detection, unless possibly for the low risk. I am fairly aggressive myself in arguing against what happens to so many low risk guys, and campaign strongly against that. That is where the problem is: uneducated patients- let's face t, that is most patients- demanding that a surgeon get it out of there. Combined with surgeons who are all too happy to either comply with such demands, or who actually influence the patient to needlessly go that route. And then destroying some of those men's QOL. That is what must be stopped. I am going to do my part, at this forum and any men I talk to. But admittedly, any advice coming from me- compared to from someon's trusted physician- is not likely to have much influence! But we can and should all keep at it. Men must be made aware of the frequent over treatment and the price they pay. That is the problem, not a blood test that alerts some fewer # of men to an aggressive cancer at an earlier stage.

BillyBob, there are many, many points on which we can agree. You have just listed many.

Let's see if we can constructively build upon this atmosphere of agreement:

1. Do we agree, also, that nobody has rationally suggested stopping all PSA testing?

2. Do we agree, also, that there have been studies which have concluded that routine PSA screening has not been shown to save very many lives--some earlier studies concluded no lives, others concluded few lives which result in more harm than benefit.

(I'm going to highlight that these two simple questions utilize 2 distinctly different terms which have been previously described in this thread: testing and routine screening.)

Can all of these points—from your last post plus these two—co-exist in your head simultaneously? Some people seem to have trouble with all these...balancing/separating their emotional side from their rational side.

Post Edited (NKinney) : 3/12/2018 12:07:46 PM (GMT-6)