Prostate.....which way to go?

[cheeryble]

(Sorry to say I cannot use rich text options to make my quotations clear as quotations. The options like italic/bold/quote etc are misted out and unclickable on my Mac have no idea why. So I'll just try with plain text and we'll see if it's understandable):

I thought I would start this topic new more specifically about prostate cancer than BPH.

I dont think Im hypochondriac, just trying to get educated, and clarify my thinking.

Three months ago, I had a PSA of 5.48 (with clear digital exam), modestly above the normal range, and the urologist suggested testing again in three months to ensure it wasnt an anomaly.

So I was tested again recently. It was not lower but it was only slightly higher at 5.55.

It is very possible the urologist will now recommend a biopsy.

Given the USPSTFs new recommendations against asymptomatic PSA testing because of the dangers of overtreatment to seemingly guard against an overall small mortality rate I have read the USPSTF document again. Given this and the Thai prevalence to follow the book......which means the old book, I decided to inform myself.

So I have spent a little time and collated and condensed evidence from studies and recommendations.

I have used only highly reputable sites like

USPSTF

cancer.org

......and another service which provides physicians condensed rundowns on medical matters called

uptodate.com

The recommendation from the people who call policy is now to avoid PSA screening.

http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm

Even the American College of Urologists, who a year ago were screaming blue murder about this recommendation, have come around and are in agreement. It is generally as a result of the dangers of impotence and incontinence weighed against the fact that most prostate cancers are microscopic and well defined to the point they possibly warrant another name, and even most genuine cancers are so slow growing they are unlikely to cause a problem. Check this, it surprised me:

5-year relative survival by stage at the time of diagnosis

Stage

local: nearly 100%

regional: nearly 100%

distant: 29%

(regional cancers....meaning gone outside the prostate to adjoining structures, but not metastisized to bones etc)

and

Survival rates

According to the most recent data, when including all men with prostate cancer: The relative 5-year survival rate is nearly 100%
 The relative 10-year survival rate is 98%
 The 15-year relative survival rate is 91%

(It seems to say that only one person in 50 who have prostate cancer will die within ten years!)

I have collated pages of what I consider the most relevant evidence, and I have bolded a choice of key points.

I offer it as a resource for anyone in my position.

I have tried not to be selective of what I want the answer to be, but the fact is that prostate cancer when I read about it does not seem quite the curse it is often considered.

There is convincing evidence that a substantial percentage of men who have asymptomatic cancer detected by PSA screening have a tumor that either will not progress or will progress so slowly that it would have remained asymptomatic for the man's lifetime.

.......speaks for itself

The U.S. trial did not demonstrate any prostate cancer mortality reduction (via PSA). The European trial found a reduction in prostate cancer deaths of approximately 1 death per 1000 men screened in a subgroup of men aged 55 to 69 years.

.......puts things in perspective, and further broad brush about PSA testing:

All-cause mortality in the European trial was nearly identical in the screened and nonscreened groups.

The average age of diagnosis was 67 years and the median age of those who died of prostate cancer from 2003 through 2007 was 80 years;

.......suggests to me that those who go on to die from diagnosed PC (what fraction is that of diagnosed cases BTW? We will learn it must be small)........take 13 years on average.

71% of deaths occurred in men older than 75 years (1).

......Well, 2.8% of American men die of PC, so this figure suggests that under 1% of them die under age 75.

This where it gets really interesting, because I read in respected places that:

Autopsy studies have shown that approximately one third of men aged 40 to 60 years have histologically evident prostate cancer (36);

and

it is clear that the reservoir of potentially detectable prostate cancer is highly age dependent and is probably in the range of 30%70% in men older than 60 years.

and

Autopsy series in men who died from other causes have shown a 30 to 45 percent prevalence of prostate cancer in men in their fifties

.......well, the mortality rate through to age 75 is only about 1% as we saw, so this clearly shows that the vast majority of cancers are not deadly, which bears out what I mentioned above, including that:

Most cases represent microscopic, well-differentiated lesions that are unlikely to be of clinical importance.

Lets move on to another conventional diagnostic tool, PSA velocity.....the rate of increase.....which my own urologist said gave cause for concern as my last annual rise was about double the normal maximum (though the recent 3 months rise was well within limits for that small period).

However we are now warned about the efficacy of PSA velocity, check out these:

1. analyses of more recent clinical data from randomized trials suggest that PSA velocity adds little predictive information to the total PSA

2. PSA measurements have considerable short-term variability [67,191]. A retrospective analysis of stored serum from 972 men found substantial year-to-year fluctuations with 44 percent of men with a PSA above 4.0 ng/mL having normal PSA findings at subsequent annual visits [192].

3. Biopsy referrals may also be based upon PSA velocity, PSA density, measurements of free or complexed PSA, and age- and race-specific PSA levels, although the clinical utility of these modifications is uncertain, and we do not recommend them for determining who should be referred for biopsy. Retrospective analyses of data from the ERSPC suggest that the predictive value of PSA for detecting cancer is not improved by incorporating PSA velocity data [70-72].

To cap things off, according to a major Stanford study, it seems the one thing that PSA is very good at predicting is the size of the prostate.....which usually grows with age, and very commonly gives urinary symptoms of BPH (benign enlarged prostate), which we are warned does NOT seem to be related to cancer.

Now prostate growth with age is pretty ubiquitous, the diameter can grow considerably and doubling is not abnormal.

Whats not so obvious is the effect on volume.

As we all know the volume of a sphere varies as the cube of the diameter. This means that if the dimensions each went up by half, which from the illustrations Ive seen seems far from exceptional, the volume would go up by 1.5 cubed, or 3.375. So the Stanford study says that your normal PSA level would more than triple, and may take you well over the limit for PSA.

______________________________

So I do this post as a collation of key points Ive collected from what seems to be modern prostate thinking. I really dont think Ive been guilty of selection bias, and it may be useful to others who may be as ignorant as I was until now.

I also write here to clarify my own thinking as I am wholly undecided on how to answer the physician if he suggests a biopsy. Because it seems to me that if PSA tests are now contraindicated for symptomless men, and I am symptomless apart from high PSA (I have modest BPH but that is generally considered to be unrelated to PC), then who else but people on the PSA borderline like myself are going to be the ones who the USPSTF says are overtreated with repercussions? I mean to say, although the USPSTF are speaking to men (and their doctors) considering a PSA test, in reality isnt it people like myself who are also perfect candidates for their message? And given that my prostate is noted as enlarged on abdominal ultrasound with the concomitant rise in PSA, should I indeed have a biopsy?

I usually respect medical advice, but is this a case where it might be better to just take ones chances....about 2.8% in a lifetime in the US......of dying of prostate cancer, never worry about it again, and abandon myself to kismet? If I read them right this is essentially what the USPSTF are saying. (Bear in mind the other wild card, that the most dangerous grade of cancer doesnt produce tenfold PSA like the normal cancer cells so one may miss that anyway....possibly the reason PSA screening has little effect on mortality). Given what we read above about a large proportion of the normal male population having discernable PC, if I get a biopsy and it has mixed results, with perhaps not only the well differentiated cells which it seems are highly unlikely to cause problems and warrant active surveillance, but some of a low or medium grade which are themselves unlikely to cause problems, where do I go then? My treatment choice is then prostatectomy at worst or at best active surveillance where I live with the regular worry that the next test (because no doubt many will be prescribed) will be a bad one? Because I really would like to avoid an unnecessary prostatectomy.

Again I don't think I'm being obsessively worried here. I think the little time I put into this is well justified would just prefer to make the best decision here given the ramifications with and without treatment.

(Looks like the best stage to abandon this process is before the PSA test not after!)

ps: I think the collation I have made would be very useful as a resource. Tried putting it into Google docs without success for public use. Any other public document suggestions? Thanks!

Edited September 30, 2013 by cheeryble

[Mighty Mouse]

I think you will totally confuse yourself and particularly your judgement by seeking more and more opinions. You will get your usual positive and negative replies.

I have two mates in Pattaya who have high reading PSA's. One mate, with a PSA reading in the mid 70's, had the biopsy, the other refuses to.

The biopsy test indicated prostate cancer but not aggressive. The other mate who refuses a biopsy, has a PSA reading in the 90's. He is now around 70 years of age and loves his once per day sex life. He said, "They're not interfering with my water works." His attitude is, 'if this kills me, I'll die a happy man."

The mate with confirmed cancer is prepared to do nothing other than monitor his situation. That means he will have more regular PSA tests and be guided by these results.

You read of other men who have panicked, had their cancerous prostate operation, and suffered the loss of their sex lives as a result. Some men can still have a meaningful sex life after the operation, but may need mechanical means to achieve an erection.

If I was in a similar position to you, I'm not 100% sure which way I'd go. I think I'd be more inclined to regularly monitor the situation and hope for a medical breakthrough.

As an encouragement, I saw a 60 Minute documentary recently where they are injecting the HIV virus (minus the harmful inclusions) into cancer patients. The HIV virus virtually kills the cancer cells. It is thought that this treatment might be advantageous to those with early signs of prostate cancer.

You would need to take into calculation your age, your health, your life expectancy, you urge for regular sex, your peace of mind etc, in making a decision as to what, if any, action to take. Only you should make this decision.

Good luck, with whatever you choose to do.

[Tolley]

You could take a more proactive approach to getting the PSA level down if you havent already.

And by that I mean losing weight , doing more exercise, checking zinc levels and eating lots of crucifate veggies. Also consider pomegranate juice as there is a bit of evidence out there on the benefits of a glass a day.. Also saw palmetto, bea sisterol , lycopene have all been mentioned before as possible ways to improve prostate function.

If the digital test is okay then I would just work on getting down the PSA level. Having said that it is being discredited anyeay by a lot of research these days so I certainly wouldnt race into a biopsy that is for sure.

[cheeryble]

I think you will totally confuse yourself and particularly your judgement by seeking more and more opinions. You will get your usual positive and negative replies.

I have two mates in Pattaya who have high reading PSA's. One mate, with a PSA reading in the mid 70's, had the biopsy, the other refuses to.

The biopsy test indicated prostate cancer but not aggressive. The other mate who refuses a biopsy, has a PSA reading in the 90's. He is now around 70 years of age and loves his once per day sex life. He said, "They're not interfering with my water works." His attitude is, 'if this kills me, I'll die a happy man."

The mate with confirmed cancer is prepared to do nothing other than monitor his situation. That means he will have more regular PSA tests and be guided by these results.

You read of other men who have panicked, had their cancerous prostate operation, and suffered the loss of their sex lives as a result. Some men can still have a meaningful sex life after the operation, but may need mechanical means to achieve an erection.

If I was in a similar position to you, I'm not 100% sure which way I'd go. I think I'd be more inclined to regularly monitor the situation and hope for a medical breakthrough.

As an encouragement, I saw a 60 Minute documentary recently where they are injecting the HIV virus (minus the harmful inclusions) into cancer patients. The HIV virus virtually kills the cancer cells. It is thought that this treatment might be advantageous to those with early signs of prostate cancer.

You would need to take into calculation your age, your health, your life expectancy, you urge for regular sex, your peace of mind etc, in making a decision as to what, if any, action to take. Only you should make this decision.

Good luck, with whatever you choose to do.

Thankyou MightMouse for a thoughtful reply.....

(though looks like you same as I didn't know about that the most aggressive cancer actually doesn't produce PSA or very little.)

You made a point

You would need to take into calculation your age, your health, your life expectancy, you urge for regular sex, your peace of mind etc,

Age approaching 65. Mum's death 95, father 89, (Aunt Lina 98!).

Generally excellent health nice low BP and exercise (not obsessively but pleasantly) daily just got back from bike ride and only a tad of extra tum.

Would not like to risk sex life unless essential, I'm not sedentary and organising my stamp collection (sorry stamp collectors) and need to continue making the world a happier place.

Peace of mind? that's one of my problems I have a longterm panic/anxiety disorder from shock so tend to worry too much. It doesn't feel like the "real me" but I can't help it.

Just trying to be rational here though......if not please say so ha-ha!

Edited September 30, 2013 by cheeryble

[Sceptict11]

There has for many years been a body of opinion which argued against routine PSA testing especially with the finding of a digitally unremarkable prostate on examination.

As you are now aware testing can and does raise dilemmas for both clinician and patient. Once an "elevated" PSA is found there has (and still is) pressure for continued investigation which in turn can lead to prostetectomy.

I can only state my own belief ( This is not advise)

I will never have a routine PSA!

If my prostate is ever found to be "abnormal" on examination (Not BPH) then I may agree to an MRI scan and a "template or saturation biopsy" (a procedure which samples more of the prostate but requires a general anaesthetic to achieve.)

Finally would I agree to radical treatment ? The honest answer is I do not know!

[cheeryble]

Thankyou Tolley and Sceptic

though Tolley PSA itself is only a marker (sometimes!) not a cause.

Are your zinc levels etc associated with cancer or BPH?

(entirely legitimate to reduce BPH if at all possible)

[Tolley]

Thankyou Tolley and Sceptic

though Tolley PSA itself is only a marker (sometimes!) not a cause.

Are your zinc levels etc associated with cancer or BPH?

(entirely legitimate to reduce BPH if at all possible)

Zinc is key to good prostate function so if you are deficient and many people are then a good zinc supplement would be helpful for all round prostate function. A liquid zinc supplement works best.

[Sheryl]

While it is true that many prostate cancers are slow growing and/or occur so late in life that odds are the man will die of something less first, should not lose sight of the fact that prostate cancer is still a major cause of death. Among cancers, second only to lung cancer in number of deaths/year in the US. Should also note that deaths from prostate cancer can involve considerable pain and suffering as it tends to metastatize to the bones.

The PSA issue is extremely complex and reflects trade-offs between sensititivity (likelihood of finding cancer if it is there) vs. specificity (risk of false positives), and cost implications also come into play. Nobody thinks the PSA is an ideal screening tool, nor is the digital exam ideal, but currently these 2 things are all that we have. This is a good but rather technical discussion http://www.uptodate.com/contents/screening-for-prostate-cancer

With a normal digital exam and a PSA towards the lower end of in the "grey zone" (>4 and <10.0), about 25% of men with a PSA in this range turn out to have cancer, 75% do not. The negative digital exam probably further lows the odds by a few points but there is still about a 1 in 5 chance of cancer and, if present , it could be slow growing or it could be aggressive.

Slow-growing, localized cancer if the prostate will usually not become life threatening for 10-15 years, for which reason advised management varies greatly by the patient's age and overall state of health. However studies have shown that after about 15 years the rate if progression to metastatic disease speeds up.

However, OP I am quite confused by statement that the DRE was normal as in another thread you have stated you have prostatic enlargement. Do you mean just that the DRE was not suspicious for malignancy, but rather showed a smooth enlargement of the prostate?

There are a wide range of options for management of prostate cancer, and these differ widely in the degree of risk to sexual function. I would suggest to cross that bridge if and when you come to it. At this point the decision is, at most, whether or not to have a biopsy.

The PSA level you have is not unusual for BPH. However the rate of rise in the PSA(more than 1.0 in 3 months) is faster than would e expected in BPH. So indeed, your urologist may recommend a biopsy.

If you are reluctant to undergo biopsy then he will continue to follow your PSA. If it keeps on rising, then I think biopsy is unavoidable given that you are a fit 65 year old. (If you don't smoke and don't drink to excess, you have a life expectancy of about 25 more years...long enough for even a slow growing prostate tumor to metastasize).

BTW did the doctor tell you to abstain from sex for 48 hours before the repeat PSA? (Should have. Ejaculatlion raises PSA by about almost a point and it takes 48hopurs to go back down).

[cheeryble]

Thankyou Sheryl

uptodate is indeed an excellent, and peer reviewed, resource.

You make an important point about low grade cancers becoming more aggressive later I was not aware of that and shall look it up.

However, OP I am quite confused by statement that the DRE was normal as in another thread you have stated you have prostatic enlargement. Do you mean just that the DRE was not suspicious for malignancy, but rather showed a smooth enlargement of the prostate?

I believe the DRE has always been unremarkable. Don't know if BPH was palpable or not it has not been mentioned I guess it's all smooth, I know about it because I have had abdominal ultrasounds with my medicals. It has been noted as prominent since 5 years ago, and last time the radiologist (?) when I asked is that my bladder and prostate said "Hmmm it's quite big" as if it was more than minimal. I could give the measurements but they're somewhat confused which I must ask about. I get modest urinary symptoms.....you might call them "beginner" symptoms, where I often wake up early to pee (not always and sometimes sleep right through for 8 hours or more) and often have to go again after a short time (incomplete evacuation). But during the day I'm generally fine and don't get "caught short".....it is not horselike any more but far from a dribble with no pressure at all......yes I'd say my symptoms are modest.

The PSA level you have is not unusual for BPH. However the rate of rise in the PSA(more than 1.0 in 3 months) is faster than would e expected in BPH. So indeed, your urologist may recommend a biopsy.

No Sheryl it has risen 1.24 from 4.23 to 5.48 over the last complete year not three months (recommended no more than 0.7ng/ml/pa)

After that rise to 5.48 it rose just 0.07 over last three months to 5.55 recently.

Funny enough although it was as low as 3.54 in 2010 it was higher at 4.48 the year before 2009 at 4.48.

If one measured the PSA velocity over the whole period 2009 to now it would be within the "normal" range and even from the low of 2010 it would almost fit.

However, as I quoted in my opening post, it looks as though "standard model" of PSA velocity has little or no predictive power and may be becoming a thing of the past:

1. analyses of more recent clinical data from randomized trials suggest that PSA velocity adds little predictive information to the total PSA
2. PSA measurements have considerable short-term variability [67,191]. A retrospective analysis of stored serum from 972 men found substantial year-to-year fluctuations with 44 percent of men with a PSA above 4.0 ng/mL having normal PSA findings at subsequent annual visits [192].
3. Biopsy referrals may also be based upon PSA velocity, PSA density, measurements of free or complexed PSA, and age- and race-specific PSA levels, although the clinical utility of these modifications is uncertain, and we do not recommend them for determining who should be referred for biopsy. Retrospective analyses of data from the ERSPC suggest that the predictive value of PSA for detecting cancer is not improved by incorporating PSA velocity data [70-72].

Funnily enough you will see I fit into (2) and went in 2009 to 2010 from above 4ng/ml to below I'm one of the 44%!

_________________________

Happy to discuss detail like above, but I guess the main reason I'm here is to air or discuss my more general proposition that if the USPSTF.....a body I truly respect from their document as superior to urologists at assessing evidence.......recommends no PSA testing for symptomless men then it implicitly means (though not explicitly stated by them) that treatment based on that PSA is also not recommended.

Am I being logical you intelligent people out there?

Edited September 30, 2013 by cheeryble

[Sheryl]

Happy to discuss detail like above, but I guess the main reason I'm here is to air or discuss my more general proposition that if the USPSTF.....a body I truly respect from their document as superior to urologists at assessing evidence.......recommends no PSA testing for symptomless men then it implicitly means (though not explicitly stated by them) that treatment based on that PSA is also not recommended.

Am I being logical you intelligent people out there?

Treatment has never been based on PSAs!

PSA is one of several diagnostic tools. It has its limitations but also its utility especially when combined with clinical symptoms and other clinical findings.

Your DRE findings cannot have been "unremarkable" if you have an enlarged prostate. And from what you say, you are not asymptomatic, so the discussion about the pros and cons of PSA screening in men with no symptoms does not apply to you. You are a symptomatic patient with an enlarged prostate and slightly elevated PSA.

Every case is different. In yours the issue is whether or not based on the total clinical picture (including but not at all limited to the PSA trends) there is enough reason to suspect malignancy that a biopsy would be indicated, or whether your sympotoms and clinical findings can reasonably be ascribed to BPH and a biopsy not done or at least postponed.

That is a complex question best answered by your urologist. You aren't going to find the answer through reading general studies and papers on PSA testing in the abstract. These are designed to develop broad recommendations (especially for things like mass screening), not to determine management of a specific case.

[cheeryble]

Thankyou kindly for your thoughts Sheryl, and sorry to be tardy.

How I have been looking at things is if I have never had an ultrasound to see prostatic enlargement and apart from very mild urinary symptoms so typical of what's considered a separate issue, BPH, I would be a symptomless person for whom PSA testing is no longer recommended. Perhaps my premise is wrong and I respect your advice and will at least see the urologist and another DRE is probably worthwhile and I can at least take his opinion about biopsy.

I guess the fact is that after coming across strangely poor practise and unintelligent decisions by medical practitioners here several times I have become hesitant to follow blindly.

You may remember I asked this urologist essentially about the rate of false negative DREs at my last appointment some months ago and what I understood him to say was if you can feel It it is already leaving the prostate.

I hope this was merely a miscommunication but I don't see how and it needs checking.

What may be well worth doing is preparing questions in advance so i get some sort of route map.

For instance I'd like to know more about your suggestion that previously inactive or slow tumours can "turn" after time and how that comes into the equation.

I might also consider that as it's only at the relatively cheap stage of consultation and testing that for something with important life ramifications it may be an option to go to a top golly perhaps at Bumrungrad.

If you can offer any questions I need answering I'd be grateful.

Thanks!

Edited October 3, 2013 by cheeryble

[Mighty Mouse]

You stated in an earlier post: I have a longterm panic/anxiety disorder from shock so tend to worry too much. It doesn't feel like the "real me" but I can't help it.

With that statement in mind, I would advise that you get a biopsy done, if for nothing else, to stop yourself unnecessarily worrying about things inside you that you can't see.

By not having a biopsy at this time, and by trying to justify your decision, you are just prolonging your worries.

A negative test result will ease your mind, a positive test result will lead to Plan B in your life. Not necessarily a death sentence.

[bunnaag]

You stated in an earlier post: I have a longterm panic/anxiety disorder from shock so tend to worry too much. It doesn't feel like the "real me" but I can't help it.

With that statement in mind, I would advise that you get a biopsy done, if for nothing else, to stop yourself unnecessarily worrying about things inside you that you can't see.

By not having a biopsy at this time, and by trying to justify your decision, you are just prolonging your worries.

A negative test result will ease your mind, a positive test result will lead to Plan B in your life. Not necessarily a death sentence.

my psa value is 34,5 I had 3 biopsies all negativ the first biopsie after PSA 18 the second after PSA 22 every time 12 samples. sometimes the tumor is at a location not normally dedected.I was told that with such a high PSA value there should be normally a tumor although sometimes inflamation

and a high BPH can be the cause.Iwas advised to check with a scan.The scan showed a suspicious area but as after one year the scan showed this area did not grow I stopped any further biopsies I forgot to mention that during the scan also the spectroskopic investigation showed only a slightly higher Cholin value and it also showed that this area was still inside the capsule. to be sure you could check with a MR sreening

[cheeryble]

Mighty Mouse

Thanks for the kind consideration......though I really have only slight concern at the moment and came here more to consider avoiding a longterm repetitive cycle of tests which......considering I once had a scan result for something else that looked very "final" :-) .......may be far more stressful than just putting it all aside and taking my chances which are pretty small.

Bunnaeg

Interesting anecdote thankyou and best of luck to you. How old are you? Are you asymptomatic apart from PSA or have urinary symptoms and BPH?

Note to self:

Would be fascinating to compare the the present overall mortality rate (2.8% USA) with the rate before modern prostate protocols started to check how much difference all the testing and treatment makes.

Edited October 3, 2013 by cheeryble

[Sheryl]

Thankyou kindly for your thoughts Sheryl, and sorry to be tardy. How I have been looking at things is if I have never had an ultrasound to see prostatic enlargement and apart from very mild urinary symptoms so typical of what's considered a separate issue, BPH, I would be a symptomless person for whom PSA testing is no longer recommended. Perhaps my premise is wrong and I respect your advice and will at least see the urologist and another DRE is probably worthwhile and I can at least take his opinion about biopsy. I guess the fact is that after coming across strangely poor practise and unintelligent decisions by medical practitioners here several times I have become hesitant to follow blindly. You may remember I asked this urologist essentially about the rate of false negative DREs at my last appointment some months ago and what I understood him to say was if you can feel It it is already leaving the prostate. I hope this was merely a miscommunication but I don't see how and it needs checking. What may be well worth doing is preparing questions in advance so i get some sort of route map. For instance I'd like to know more about your suggestion that previously inactive or slow tumours can "turn" after time and how that comes into the equation. I might also consider that as it's only at the relatively cheap stage of consultation and testing that for something with important life ramifications it may be an option to go to a top golly perhaps at Bumrungrad. If you can offer any questions I need answering I'd be grateful. Thanks!

BPH is not a separate issue, it is a known cause of elevated PSA. And you are not asymptomatic. You are a patient with known BPH and accompanying symptoms thereof whose PSA levels may be increasing more rapidly than is usual in BPH (but whose prostate on digital examination I gather is not suspicious for malignancy i.e. is enlarged but smooth, although this point is not fully clear). The issue is whether or not a biopsy is warranted under these circumstances. This is a totally different case and question than the issue of PSA screening in asymptomatic people without known prostate disease.

If you do not have confidence in your urologist I suggest you change to another one. If you advise where you live, perhaps I can suggest one. You should of course bring complete medical records with you when making a change.

[puck2]

First, many thanks to cheeryble and Sheryl for your inputs.

An excerpt of the research posted from Sheryl - # 6 with a suggested headline: What may elevate the PSA levels?

PSA has a half-life of 2.2 days, and levels elevated by different benign conditions will have variable recovery times. PSA testing should be deferred accordingly:

• Digital rectal examination (DRE) has minimal effect on PSA levels, leading to transient elevations of only 0.26 to 0.4 ng/mL, and PSA can be measured immediately after DRE

• Ejaculation can increase PSA levels by up to 0.8 ng/mL, though levels return to normal within 48 hours. We do not usually ask men to abstain from sexual activity prior to PSA measurement. However, if an initial measurement is high enough to potentially prompt an intervention (ie, biopsy), but close to a borderline value, it is appropriate to repeat the PSA measurement after having the man abstain from ejaculation for at least 48 hours.

• Bacterial prostatitis may elevate PSA levels, but they generally return to baseline six to eight weeks after symptoms resolve. Asymptomatic prostatic inflammation can also elevate PSA levels, but this diagnosis is made on biopsy and so cannot generally be used to defer screening tests.

• Prostate biopsy may elevate PSA levels by a median of 7.9 ng/mL within 4 to 24 hours following the procedure. Levels will remain elevated for two to four weeks. Similarly, a transurethral resection of the prostate (TURP) can elevate PSA levels by a median of 5.9 ng/mL. Levels will remain elevated for a median time of approximately three weeks. A screening PSA test should not be performed for at least six weeks following either of these procedures.

• Acute urinary retention may elevate PSA levels, but the levels can be expected to decrease by 50 percent within one to two days following resolution. A screening PSA test should not be performed for at least two weeks following an episode of acute urinary retention

• (May i add by myself: before the PSA testing you should also avoid riding a bicycle for the same reason, elevating PSA levels)

This could concern you. Please consider it before your next PSA test.

[cheeryble]

I went to see the urologist yesterday and he is abroad a few days so will see after.

In the meantime here is the information I collected which educated....and rather surprised....me. Bear in mind it is a congeries from various sources so a bit jumbled, and I have inserted most of the UpToDate rundown for added breadth (it's a peer reviewed condensed information source for physicians).

The sources are all highly reputable.

The bolding of keypoints is mine:

PROSTATE INFO collated .pdf

Edited October 8, 2013 by cheeryble

[cheeryble]

First, many thanks to cheeryble and Sheryl for your inputs.

An excerpt of the research posted from Sheryl - # 6 with a suggested headline: What may elevate the PSA levels?

PSA has a half-life of 2.2 days, and levels elevated by different benign conditions will have variable recovery times. PSA testing should be deferred accordingly:

• Digital rectal examination (DRE) has minimal effect on PSA levels, leading to transient elevations of only 0.26 to 0.4 ng/mL, and PSA can be measured immediately after DRE

• Ejaculation can increase PSA levels by up to 0.8 ng/mL, though levels return to normal within 48 hours. We do not usually ask men to abstain from sexual activity prior to PSA measurement. However, if an initial measurement is high enough to potentially prompt an intervention (ie, biopsy), but close to a borderline value, it is appropriate to repeat the PSA measurement after having the man abstain from ejaculation for at least 48 hours.

• Bacterial prostatitis may elevate PSA levels, but they generally return to baseline six to eight weeks after symptoms resolve. Asymptomatic prostatic inflammation can also elevate PSA levels, but this diagnosis is made on biopsy and so cannot generally be used to defer screening tests.

• Prostate biopsy may elevate PSA levels by a median of 7.9 ng/mL within 4 to 24 hours following the procedure. Levels will remain elevated for two to four weeks. Similarly, a transurethral resection of the prostate (TURP) can elevate PSA levels by a median of 5.9 ng/mL. Levels will remain elevated for a median time of approximately three weeks. A screening PSA test should not be performed for at least six weeks following either of these procedures.

• Acute urinary retention may elevate PSA levels, but the levels can be expected to decrease by 50 percent within one to two days following resolution. A screening PSA test should not be performed for at least two weeks following an episode of acute urinary retention

• (May i add by myself: before the PSA testing you should also avoid riding a bicycle for the same reason, elevating PSA levels)

This could concern you. Please consider it before your next PSA test.

Thankyou Puck.

The fact is that the one thing that really can have a lasting large affect.....in fact a proportional effect......on PSA levels is the prostate volume.

Bearing this in mind I intend to ask the urologist if he can bring up my old ultrasound prostate measurements and try to judge if my PSA level is most likely simply down to a rise in my prostate volume caused by BPH.

Edited October 8, 2013 by cheeryble

[Sceptict11]

I went to see the urologist yesterday and he is abroad a few days so will see after.

In the meantime here is the information I collected which educated....and rather surprised....me. Bear in mind it is a congeries from various sources so a bit jumbled, and I have inserted most of the UpToDate rundown for added breadth (it's a peer reviewed condensed information source for physicians).

The sources are all highly reputable.

The bolding of keypoints is mine:

An interesting collation of fact!

The information will be inaccessible to many owing to the academic/scientific jargon used.

What is clear is that "screening" by PSA is a very blunt tool which leads potentially to over diagnosis and treatment. .

An elevated PSA places both patient and doctor between a rock and a hard place.

There are no clear answers to this problem which is similar to the problems associated with female breast screening by mammogram which has resulted in many ladies being over diagnosed and treated for "disease" which would have a very low risk of mortality.

[Sceptict11]

Forgot to give this link

http://www.cancerresearchuk.org/cancer-info/spotcancerearly/screening/breastcancerscreening/breast-cancer-screening

Note !

"for every life saved from breast cancer by screening, around three women are overdiagnosed".

Some of these ladies will undergo mastectomy which is of no benefit and all will suffer some degree of psychological harm.

Edited October 8, 2013 by Sceptict11

[Tolley]

I went to see the urologist yesterday and he is abroad a few days so will see after.

In the meantime here is the information I collected which educated....and rather surprised....me. Bear in mind it is a congeries from various sources so a bit jumbled, and I have inserted most of the UpToDate rundown for added breadth (it's a peer reviewed condensed information source for physicians).

The sources are all highly reputable.

The bolding of keypoints is mine:

An interesting collation of fact!

The information will be inaccessible to many owing to the academic/scientific jargon used.

What is clear is that "screening" by PSA is a very blunt tool which leads potentially to over diagnosis and treatment. .

An elevated PSA places both patient and doctor between a rock and a hard place.

There are no clear answers to this problem which is similar to the problems associated with female breast screening by mammogram which has resulted in many ladies being over diagnosed and treated for "disease" which would have a very low risk of mortality.

It certainly makes a very good case for avoiding visiting doctors as they are a potential health hazard

[Mighty Mouse]

An elevated PSA places both patient and doctor between a rock and a hard place.

You're looking at this from a patients point of view. You don't know how good or bad your current situation is.

Look at the situation from your doctors point of view. He/She doesn't know either.

So we have a bit of a stalemate. Your doctor should not recommend any course of action. He/she should make you fully aware of all your options and leave any final decision to you.

That is where you now stand. You are searching the internet for more and more information but will it be enough information to allow you to accurately assess whether or not you have cancer or whether it is prudent to sit and do nothing?

If you choose to act, a biopsy might provide a more accurate answer, whereas if you choose to do nothing, the onset of serious pain might also provide you with an answer.

Keep in mind, timing is everything.

The choice is all yours.

[CPH]

The discussion in the papers from the OP is about PSA screening on perfectly normal population without any prior symptoms.

Maybe a general PSA screening would overstate some of the findings.

However, in the OPs case there are symptoms which could be cancer. That is a complete other case where PSA tests should be done

and based on the results a biopsy should be done and based on the result of the biopsy if positive surgery or radiation treatment. All the other talk is only to confuse things.

[Sheryl]

Yes, OP's case is not one of PSA screening in an asymptomatic patient without known prostate disease. He IS symptomatic and has known prostate disease.

It also appears that to date his urologist has not recommended biopsy, OP just anticipates that he might.

[Sheryl]

Forgot to give this link

http://www.cancerresearchuk.org/cancer-info/spotcancerearly/screening/breastcancerscreening/breast-cancer-screening

Note !

"for every life saved from breast cancer by screening, around three women are overdiagnosed".

Some of these ladies will undergo mastectomy which is of no benefit and all will suffer some degree of psychological harm.

Nobody perfroms or undergoes mastectomy based on a mammogram result. Mammograms may lead to unnecessary biopsies (unnecessary in retrospect) but not to unnecessary mastectomies..which in any case are not nowadays the most common treatment for early breast cancer in situ.

With any screening test there is a trade-off between sensitivity (ability to detect a condition if it is there) and specificity (risk of a false negative). A screening test is just that..a tool for screening, flagging cases for further diagnostic evaluation. Screening tests are not in themselves diagnostic nor are they expected to be.

And with any screening test there will be both false negatives and false positives. If one wants to minimize the false negatives, i.e. to maximize the chance the screening will flag cases that have the problem, one has to accept an increased number of false positives. If you want to remove the possibility of false positives, you will inevitably increase the numbers of false negatives. It is generally better to err on the side of the former.

[Tolley]

Forgot to give this link

http://www.cancerresearchuk.org/cancer-info/spotcancerearly/screening/breastcancerscreening/breast-cancer-screening

Note !

"for every life saved from breast cancer by screening, around three women are overdiagnosed".

Some of these ladies will undergo mastectomy which is of no benefit and all will suffer some degree of psychological harm.

Nobody perfroms or undergoes mastectomy based on a mammogram result. Mammograms may lead to unnecessary biopsies (unnecessary in retrospect) but not to unnecessary mastectomies..which in any case are not nowadays the most common treatment for early breast cancer in situ.

With any screening test there is a trade-off between sensitivity (ability to detect a condition if it is there) and specificity (risk of a false negative). A screening test is just that..a tool for screening, flagging cases for further diagnostic evaluation. Screening tests are not in themselves diagnostic nor are they expected to be.

And with any screening test there will be both false negatives and false positives. If one wants to minimize the false negatives, i.e. to maximize the chance the screening will flag cases that have the problem, one has to accept an increased number of false positives. If you want to remove the possibility of false positives, you will inevitably increase the numbers of false negatives. It is generally better to err on the side of the former.

Nonetheless it is very concerning that a quite a significant percentage of both breast cancer and prostate cancer screenings are leading to unecessary interventions.

It leaves patients in a very difficult situation should they test positive.

[cheeryble]

I think Sheryl's last post was excellent and also that Tolley's point

It leaves patients in a very difficult situation should they test positive.

is the crux of the matter here.

I found one paragraph in the collection I posted particularly telling....

• A study examined the number of men diagnosed and treated for prostate cancer in the United States (US) each year after 1986, the year before PSA screening was introduced, until 2005 [157]. The study estimated that approximately 1.3 million additional men were diagnosed with prostate cancer as a result of screening, of whom approximately 1 million were treated. Assuming that the entire decline in prostate cancer mortality in the US from 1986 through 2005 was due to screening, an extremely optimistic assumption for PSA screening, approximately 23 men had to be diagnosed and 18 men treated for prostate cancer to prevent one death. The authors concluded that most of the additional cases of prostate cancer AAsfound since 1986 represent overdiagnosis.

It was no doubt with all the best intentions that over three quarters of cancer-diagnosed men were "treated" (whatever that means......but I'll assume the worst). What looks certain is that "treatment" seems to have a very small effect on your chances of survival.

Hopefully even in the small number of years since this study period urologists have grown more discriminating between varieties of cancerous tissue and routes to go, but again one must assume the worst.....especially in a what one could call a nation not at the forefront......and try to steer the most sensible course possible. (To be fair if one was a urologist oneself one would probably err on the safe side!)

The fact is it's a big complex picture, a difficult one to weave, which in any case boils down to "Are you feeling lucky punk?"

I guess what we're here for is to help us to optimise the our chances of being lucky.

Then we can "Forget about it!"

Edited October 10, 2013 by cheeryble

[Sheryl]

The situation with prostate cancer is very much confounded by the fact that many of the men diagnosed were elderly. The older someone diagnosed with cancer is, the more likely that they will die of something other than the cancer, especially if it is of a slow growing type.

The study refers to the period 1996 - 2005. In recent years there has been a lot of attention given to this issue and to taking a "wait and see" rather than aggressive approach to slow-growing prostate tumors in older men. I doubt you would find such a high percentage of treatment now.

But again, must note that aggressive tumors, and prostate cancer in younger men, are an entirely other matter.

[cheeryble]

The situation with prostate cancer is very much confounded by the fact that many of the men diagnosed were elderly.The older someone diagnosed with cancer is, the more likely that they will die of something other than the cancer, especially if it is of a slow growing type.

Another excellent and important point

The study refers to the period 1996 - 2005. In recent years there has been a lot of attention given to this issue and to taking a "wait and see" rather than aggressive approach to slow-growing prostate tumors in older men. I doubt you would find such a high percentage of treatment now.

Have you come across this enlightenment here in Thailand Sheryl?

But again, must note that aggressive tumors, and prostate cancer in younger men, are an entirely other matter.

Of course Sheryl.....and it puts another spanner in the washing machine that a "younger man" (which in prostate terms may even apply to me at 64/65!) will have to think about a sleepy tumour "waking up" in future and decide on action now or later.This aspect you brought up has not been in the literature I've read through. Any refs would be most appreciated.regardsCheeryble Edited October 10, 2013 by cheeryble

[puck2]

Prostate (sreening) and PSA, that is like opening or not a box somebody has put in front of your door. You don't know the content. Inside there may be some ordinary air, it may contain some sweets or fruits, but it may contain an explosive/bomb. Nobody can tell you in advance what will be when you open the box.

Hold this in mind concerning prostrate and PSA re. screening.

You open the box if you want to know what is inside. Can be a good or bad item, or just only air.

STEP 1

The main problem: do you want to open the box or not?

• You don't open the box because your neighbor has got the same box and said to himself: why bother, why should it contain an explosive?

No prostate screening - no sorrows about your health. But you don't feel safe. You have doubts because you read once prostate cancer(=PC) has a high share in man's mortatlity rate.

• You open the box, you want to know what is inside. You must be aware of a danger you can die of. Opening the box means also you can prepare yourself against a dangerous explosion or you can destroy the explosive with the support of a specialist. The result: now you know if the content of the box is dangerous or not.

If you do the prostate screening

• you may receive the box's sweet content = all okay. You have a sigh of relief.

• you may see a content that looks dangerous, but you are able to remove it = curable cancer or it isn't cancer at all.

• you may see a dangerous package inside = cancer in the palliativ (not curable) stadium. It's too late then.

I use this a comparison to show that there is a pain threshold for some people.

If you are strong enough to suppress all evil thoughts of a PC then you refrain from screening.

If you would like to control your health/life you do a screening. Nowadays you nearly cannot avoid it if you have a constant health check-up which normally includes measuring the PSA level. The box is already open.