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Harvard Health Blog
Time to rethink the debate on PSA testing
- By: Steven J. Atlas, MD, MPH, Contributor
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High PSA value will have significant psychological impact on patients.
We have many patients (non metastatic cases) who are worried about small changes in numbers. Due to the fear factor patients won’t be able to contribute to the open discussion. Ultimately it is the doctor who has to take the informed (to the self) decision. Again doctors are handicapped here as well, 1. Obligations in reaching targets in a corporate setup . 2. Fear of loosing patient to some other hospital. 3. Reputation, what if things go other way around even after taking best decision-this in fact contributing to over or under diagnosis.
The only way is ” informed unified ethical scientific evidence based approach on humanitarian basis”.
But, People have to be aware of the fact they should talk to their doctors whenever they have issues like recurrent infections, incontinence, retention, secretions, obstructed flow, burning and itching in the region, sex drive etc….so that doctors can diagnose and treat accordingly.
As a prostate cancer patient, I have a biased opinion.
My PSA was elevated, sand the MRI showed a suspicious area in my prostate. The biopsy revealed cancer (3+4). I was treated and a followup MRI 6 months later showed nothing suspicious,
To be sure a biopsy was performed and once more a sample revealed cancer (3*4) in the other side of my prostate. To me this shows that only a biopsy can provide valid results.
I am being treated at Memorial Sloan Kettering by experts. My last procedure was October 2,2017.
I think the recommendation of shared decision making between the patient and dictot is poor. Why would the opinion of one doctor be better then a clear consensus of many? My doctor just tells be that his practice recommends PSA testing without any real justification. Men and their need a clear and solif recommendation whether to test or not to test.
I believe that two items are consistently overlooked in the debate on the usefulness of the PSA test. One is that the absolute value of PSA (largely dependent on the size of the prostate) is less important than the year-over-year change. For example, my PSA increased 25% in one year. This was followed by very successful (no incontinence or impotence) treatment at RCOG (Radiotherapy Clinics of Georgia) and PSA below detection limits 13 years later. The other is the large drop in cancer deaths after the initiation of PSA testing. CDC numbers indicate 168.6 per 100K in 1999 and 95.5 in 2014. As a (non-medical) scientist, I believe that, properly used, the PSA test is very valuable.
“… prostate cancer therapies for those with serious disease needing treatment have improved a great deal since these trials were done, lowering the value of earlier detection.”
I disagree. Early detection is always beneficial. The doctor and patient can follow up with better non-invasive blood tests like the 4KScore which assesses PCa aggressiveness before moving to MRI or biopsy.
I wish my PCa was detected earlier before it had escaped the gland. I have had psa tests annually since age 40 but was not aware that finasteride , which I was taking for BPH, lowered test results by half. At age 68 when my psa suddenly doubled from 2.7 to 5.4 , I had a biopsy which found gleason 9 PCa. and I was staged pt1c. However, after radical prostatectomy , my pathology came back as stage pt3b! Since then I’ve had ADT and RT three times due to recurrence.
a new study recently re-examined these two (now old) trials and concluded that they really aren’t as different as we thought
Unfortunately such mathematical models of mean lead times largely ignore overdiagnosis bias: http://www.nature.com/bjc/journal/v109/n7/full/bjc2013427a.html?foxtrotcallback=true
Rather, it is time to figure out how to better inform all eligible men about the benefits and harms of PSA testing.
Unfortunately, little progress will be made on this while most doctors believe it is more important to PSA screen men without fully informing them than to fully inform them: https://health.usnews.com/health-care/articles/2017-04-11/many-docs-dont-discuss-prostate-cancer-screening-pros-and-cons
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