4 ms·

Your BF's doctor is uninformed and offering bad advice. Fact is, most men over age 70 do have elevated PSA due to small amounts of low grade prostate cancer ce

Your BF's doctor is uninformed and offering bad advice. Fact is, most men over age 70 do have elevated PSA due to small amounts of low grade prostate cancer cells (Gleason score of 3+3). Usually it advances slowly, never growing beyond the bounds of the prostate gland before the patient dies from some other cause. But an elevated PSA (over 1 and below 10) in someone younger than 70 should not be ignored. Often a second PSA test is done perhaps a month later to confirm the first score and to see if the number is rising quickly. If repeated tests do not show PSA elevation AND the score is low, often the urologist will recommend a "monitor it, and wait and see" strategy. If the PSA number is high or is rising, the next step is to get a biopsy where 12 to 18 samples of tissue are taken from the prostate to see how much of the gland has cancerous cells (Gleason 3, 4, or 5). I know something about this topic because a routine PSA test at age 55 showed that I had asymptomatic cancer in 80% of my prostate. Luckily it was removed surgically. But if my doctor was as casually unconcerned as your BF's doctor, my cancer would have metastasized and by now it would be incurable.

fasteo 6y ago
>>> Your BF's doctor is uninformed and offering bad advice. I wouldn't go that far. In your n=1 case it seems clear that not monitoring PSA would have been an error, but there exists a debate on the risk/benefit of this test. Namely, the unnecessary suffering that it can inflict to a healthy person with elevated PSA. This is a good review [1] "To screen or not to screen for prostate cancer? This remains an important question. Screening relies on a highly imperfect measure, the prostate-specific antigen (PSA) blood test, which is prone to false-positive results. And with mounting evidence that survival benefits from screening pale in comparison with the harms from overtreatment — particularly incontinence and impotence — the pendulum has steadily swung away from it. Still, screening research continues, in the hopes that some lifesaving benefits may be found." [1] https://www.health.harvard.edu/blog/new-study-once-again-casts-doubt-on-psa-screening-2018040613526 https://www.health.harvard.edu/blog/new-study-once-again-cas...
- randcraw 6y ago
  I'm keenly aware of the PSA debate. Policy about its proper use been see-sawing back and forth for a decade. Starting about 10 years ago, just before it mattered to me, official policy decided to NOT screen using the PSA test. The belief was that underinformed primary care docs were overreacting to a high PSA number and ordering too many biopsies which often led to "unnecessary" infections. Of course, the right response was to do a better job of interpreting the test results, ideally to refer the results to a more expert urologist before doing a biopsy, not to cut back on the test. Given its low cost ($50) and very high sensitivity, the PSA test provided a very valuable service that could be equalled by no other test. Physical exam is often wrong, missing a large fraction of positive cases of cancer. And biopsies introduce infection most often in older patients. Younger ones can tolerate biopsy better, but were disallowed from PSA screening entirely due to this overprotective policy. The right solution was clearly to interpret the PSA test results more judiciously by introducing more expertise prior to biopsy, knowing that PSA is overly sensitive for diagnosing cancer. Fortunately the official policy has since been reversed, and PSA has returned to routine use -- now with inclusion of a second test or a urologist prior to biopsy. The same blunder took place in mammographies at about the same time. Too many false positives led to too many biopsies and thus routine screening with mammography was deemed unacceptable and it was deprecated as well. Fortunately that overreaction has also ended. Sensitive medical tests are essential. Overreaction to possible misinterpretation of positive results by inexpert GPs is the problem, not the test itself. I routinely thank the stars above that my GP was expert enough to know that.

fasteo 6y ago

>>> Your BF's doctor is uninformed and offering bad advice. I wouldn't go that far. In your n=1 case it seems clear that not monitoring PSA would have been an error, but there exists a debate on the risk/benefit of this test. Namely, the unnecessary suffering that it can inflict to a healthy person with elevated PSA. This is a good review [1] "To screen or not to screen for prostate cancer? This remains an important question. Screening relies on a highly imperfect measure, the prostate-specific antigen (PSA) blood test, which is prone to false-positive results. And with mounting evidence that survival benefits from screening pale in comparison with the harms from overtreatment — particularly incontinence and impotence — the pendulum has steadily swung away from it. Still, screening research continues, in the hopes that some lifesaving benefits may be found." [1] https://www.health.harvard.edu/blog/new-study-once-again-casts-doubt-on-psa-screening-2018040613526 https://www.health.harvard.edu/blog/new-study-once-again-cas...

randcraw 6y ago
I'm keenly aware of the PSA debate. Policy about its proper use been see-sawing back and forth for a decade. Starting about 10 years ago, just before it mattered to me, official policy decided to NOT screen using the PSA test. The belief was that underinformed primary care docs were overreacting to a high PSA number and ordering too many biopsies which often led to "unnecessary" infections. Of course, the right response was to do a better job of interpreting the test results, ideally to refer the results to a more expert urologist before doing a biopsy, not to cut back on the test. Given its low cost ($50) and very high sensitivity, the PSA test provided a very valuable service that could be equalled by no other test. Physical exam is often wrong, missing a large fraction of positive cases of cancer. And biopsies introduce infection most often in older patients. Younger ones can tolerate biopsy better, but were disallowed from PSA screening entirely due to this overprotective policy. The right solution was clearly to interpret the PSA test results more judiciously by introducing more expertise prior to biopsy, knowing that PSA is overly sensitive for diagnosing cancer. Fortunately the official policy has since been reversed, and PSA has returned to routine use -- now with inclusion of a second test or a urologist prior to biopsy. The same blunder took place in mammographies at about the same time. Too many false positives led to too many biopsies and thus routine screening with mammography was deemed unacceptable and it was deprecated as well. Fortunately that overreaction has also ended. Sensitive medical tests are essential. Overreaction to possible misinterpretation of positive results by inexpert GPs is the problem, not the test itself. I routinely thank the stars above that my GP was expert enough to know that.