Comments on: The PSA test: Potentially Stimulating Anxiety?

By: xray

xray — Thu, 01 Jan 1970 10:00:00 +0000

I'm pleased for Gavin that his biopsies keep coming back clear despite high PSA readings.
Unfortunately, a few years after two TURPs, my father had a PSA of 19, and a Gleason of 7. Being over 70 and the cancer having spread outside the prostate capsule, his urologist wouldn't operate. Radiotherapy and 2 years of hormone therapy followed. Cured or controlled? I don't know.
I still hold his GP and urologist responsible - neither did a PSA test in the few years between his last TURP and cancer diagnosis, while the level was clearly rising. In my father's case, the PSA test was the first sign of something that had been wrong for some time.
Some 'red book' that GPs use doesn't even recommend PSA tests be administered - GPs are to wait for patients to bring it up. At least the version I found online. Nice. I love having to do everything myself - like Gavin, having to work out the risks, gather the data, request what treatment I think I need.
And doctors wonder why patients (and in my case, their worried and cranky children who accompany them to appointments) question them, seek second opinions and go their own way.

By: Dr Eileen Rafter

Dr Eileen Rafter — Thu, 01 Jan 1970 10:00:00 +0000

It is refreshing to read an article from a patient questioning the value of PSA tests for screening of prostate cancer, something that is an ongoing debate amongst doctors. However I do disagree with the implication (that doctors are mainly ordering the tests to earn more income) in Professor Mooney’s final rhetorical question ‘Can we trust our fee-for-service doctors to do the right thing…..when there is a fee attached?”
As a GP I frequently get requests for a PSA test as part of a routine health check. Patients often look taken aback when I ask them about symptoms and proceed to discuss issues such as probabilities and the risks and benefits of screening. After five minutes extra consult time (with no extra fee) they usually want the test anyway.
As with other GPs the cost of a PSA test is a deterrant rather than an encouragement for me to order it. I receive no extra income (above the routine consult fee) for ordering the test but I am well aware that there is a cost to myself as a tax payer, through the cost of the pathology to medicare. However this cost is not enough to help me swim against the tide of society and patient expectation.
Perhaps less PSA tests and biopsies will be done when doctors have less fear of being sued for missing the improbable.

By: Spectator

Spectator — Thu, 01 Jan 1970 10:00:00 +0000

If a Health Economist can’t get accurate, unbiased information what hope for the punters. Disregarding the PSA issue, having a biopsy is no picnic. There is a risk in having a biopsy and a percentage of men require the urgent attention of a vascular surgeon when ‘things go wrong’…but just try and get figures on that one..everyone runs for cover. And then if the biopsy shows you have prostate cancer…what type of treatment do you have? A radical prostatectomy(surgery), low or high dose brachytherapy(radioactive seeds), radiotherapy or hormonal therapy? Or do you opt for ‘watchful waiting’? Where you end up will depend on which urologist you have been referred to; only a handful offer brachytherapy and not all choose to recommend a consultation with a radiotherapist who treats a significant number of men with prostate cancer. Volume as with the treatment of most cancers is important in terms of acquired skills and good outcomes. But how do you find out that sort of information? Most GPs don’t have it and Cancer Helplines are not permitted to specifically recommend particular specialists. So - most men end up relying on the urologist to whom they have been referred and, if they are really lucky, that urologist will explain all the options. But don’t bet on it. And make sure that the next time your GP takes some blood that he/she confirms exactly what tests he/she is requesting. PSA tests are not recognised as an effective screening procedure. They may be in the future. Meanwhile, trust another older acronym: the ‘DRG’ - Digital Rectal Examination.

By: Graeme Major

Graeme Major — Thu, 01 Jan 1970 10:00:00 +0000

PSA concentration can rise dramatically with sexual activity. The test should not be taken within at least two weeks of complete celibacy.

Very few doctors even know this, leave alone tell their patients to desist from any amorous or sexually arousing pursuits before having the blood sample taken.

By: Peter Mair

Peter Mair — Thu, 01 Jan 1970 10:00:00 +0000

My 65 yro prostate (gleason score 7) was removed in August, some 3 months after twice getting a higher PSA reading. My regret is about not insisting on a quicker biopsy — of accepting the initial complacency of ‘probably no need to worry’.

I felt the internet coupled with the medical diagnosis gave enough information for me to confidently proceed to ‘get it out’ with little further delay.

The surgery (at the Mater) went well: I recovered very quickly and I have no residual problems — bar the worry of a recurrence, and the need to proceed to radiotherapy.

In short, if you are over 60 have a PSA test twice a year and respond immediately to any increase — and waste no time getting the biopsy.

Depending on that outcome the next steps are clear enough.

By: Gerard Byrne

Gerard Byrne — Thu, 01 Jan 1970 10:00:00 +0000

See also the article by HH Dubben in Lancet Oncology - March 2009; 10(3): 294-8, which suggests that it might not ever be feasible to obtain sound scientific evidence on which to base screening decisions for prostate cancer.

By: Wayne Robinson

Wayne Robinson — Thu, 01 Jan 1970 10:00:00 +0000

I strongly intend never have a PSA as a screening test for prostatic carcinoma. The trouble is that a raised level isn’t sufficiently predictive of prostatic carcinoma, with too many false negatives, and even if a biopsy does show carcinoma, it is impossible on the biopsy alone to decide whether the carcinoma is going to be clinically significant or indolent, as many actually are. Particularly since a positive biopsy usually leads to a radical prostatectomy. The same thing happens with screening mammography. The biological history of cancer is very variable; some are very aggressive and kill rapidly and at the other extreme, there are tumours that are very indolent, and everything in between.

By: Graeme Major

Graeme Major — Thu, 01 Jan 1970 10:00:00 +0000

PSA concentration can rise dramatically with sexual activity. The test should not be taken within at least two weeks of complete celibacy.

Very few doctors even know this, leave alone tell their patients to desist from any amorous or sexually arousing pursuits before having the blood sample taken.

By: DavidH

DavidH — Thu, 01 Jan 1970 10:00:00 +0000

The information you need is available in massive amounts on the internet, but you need competent medicos to guide you through it. I was fortunate enough to find (after some false starts) a doctor who could answer my questions in terms of probabilities. Check all your sources (including Croaky) but for me the end game came to:
- There are three equally effective treatments – radical surgery, robotic surgery and brachytherapy (radiation).
- Each have about the same outcome – about an 85% chance of no recurrence of the disease within 5 years.
- Each have the same side-effects, although with different probabilities for each treatment.
- So you end up choosing a method on the basis of its side effects.
There doesn’t seem to be data for more than 5 years but blind extrapolation to 10 years would imply around three quarters of patients would still be disease free then. Not wonderful odds, but this seems to me to support the idea that, if you’re over 70 and haven’t yet got prostate cancer, forget it. It will kill you no sooner than other causes.