10 ms·

The paradox of the Prostate-Specific Antigen (PSA) test

32 points by anarbadalov 5y ago

pfortuny 5y ago
The trouble with preventative medicine is that it is creating artificial anxiety on the basis of the possibility of illness. Thus, we the people are constantly in a state of "possible sickness" and instead of thinking of illness as what it has always been (a state of lack of health which manifests in lack of well-being), we are made to think of illness as "having a wrong parameter". The acceptance of mortality (or its lack) is key to this. Or, on the other hand, we can think of health as "public health", and forget about the individual. But I reject this proposition.
- pc86 5y ago
  I honestly have no idea what you're trying to say. Are you against preventative medicine? Are you against public health initiatives?
  - someguydave 5y ago
    I am against preventative medicine in the case where it has not been shown to have benefits worth the costs.
- dlisboa 5y ago
  We are always possibly sick at all times, getting a test done will not prevent or change that. The fact that we don’t get anxiety daily is because we forget about it and move on with life. But what is worse? Getting anxiety over being sick for a couple days or living in regret because you didn’t get a simple test to discover something potentially treatable early on? If you “accept mortality” in the way you seem to imply then there’s no need to worry about health anyway. Should I just “accept” that if it wasn’t prostate cancer something else would’ve killed me anyway, so why check?
- neogodless 5y ago
  > The trouble with preventative medicine is that it is creating artificial anxiety on the basis of the possibility of illness The possibility of illness exists with or without preventative medicine. Preventative medicine decreases that possibility, and reduces anxiety. > The acceptance of mortality (or its lack) is key to this. Whether or not you accept mortality has no effect on whether it is a condition we all share. Though it's unclear to me if you wish for everyone to accept mortality, or reject it. > Or, on the other hand, we can think of health as "public health", and forget about the individual. I'm trying not to read something into this, but it's hard not to. In general, health is personal/individual, even if the way it affects you can then affect others. Of course, in the case of infectious disease, individual infection leads to transmission and public spread, so it should be thought of at more than just an individual level. (That isn't really relevant for the PSA, though. That's quite individual.)
- xboxnolifes 5y ago
  > The trouble with preventative medicine is that it is creating artificial anxiety on the basis of the possibility of illness. I don't see it this way. Regardless of the existence of preventative care, what brings anxiety is the knowledge of the existence of the illness and the possibility of being sick. The preventative care (assuming we mean test/monitoring and not constant medication) is what shows me that the anxiety is unfounded.
taylodl 5y ago
I don't understand this thinking at all. Most prostate cancers are a non-issue if caught and treated early. As my father's doctor told him - prostate cancer, if caught early, is largely a disease you die with, not a disease you die from. The PSA is the best tool we have for early diagnosis and treatment. I have the test done as part of my annual checkup and have done so for the past 15 years. Let me put it this way - it's a heckuva lot less invasive than a colonoscopy!
- hef19898 5y ago
  And I recommend both! No matter how invasive the test, cancer is worse.
  - compiler-guy 5y ago
    Malignant cancer is certainly worse, but many prostate cancers that are exposed by this test are totally benign.
    - hef19898 5y ago
      And not discovering early might very well mean the cancer becomes a lot more serious. Never understood the fear of medical exams.
      - compiler-guy 5y ago
        Over treatment is a real issue and can create more serious issues that the original problem.
  - throwawayboise 5y ago
    There absolutely are things worse than cancer.
    - hef19898 5y ago
      Depends on the cancer, doesn't it?
zwieback 5y ago
I'm one data point pro PSA: at 43 I had elevated levels, biopsy, detected cancer, prostatectomy followed by full recovery. I can also attest to the anxiety about the two big Is: incontinence and impotence. Luckily I had a great surgeon who'd done hundreds of prostatectomies and everything turned out well. The urologist who originally treated me gave me one good piece of advice, he said "statistically you're not likely to die of this but the problem with statistics is that they may not apply to you". When the surgeon removed my prostate he said that I would have developed symptoms sooner or later even if it hadn't metastasized.
- sethammons 5y ago
  > "statistically you're not likely to die of this but the problem with statistics is that they may not apply to you" I like that. A lot. Thanks for the quote.
stevespang 5y ago
Another of these "mindless" ramblings with no firm conclusion on a subject which could be distilled into just a few bullet points for an executive summary
zanethomas 5y ago
I had a positive PSA test 11 years ago. Followed by a confirming biopsy. Followed a couple days later by a robotic surgery. Problem solved, obviously, I'm still here. <g>
AlanYx 5y ago
This article isn't very good IMHO because it focuses on emotional considerations rather than the underlying math. The core problems with the PSA test is that it has relatively low statistical specificity and it hasn't been shown to have any statistically significant effect on mortality in aggregate, and the resulting treatment options do have statistically significant morbidity. Hence all the debate about when, how often, and for whom. All the arguments about increased anxiety are pretty unhelpful and obscure the underlying statistical challenges.
- zwieback 5y ago
  My understanding was that the article was specifically meant to be about the emotional considerations, which are a result of the statistical challenges. BTW: one flipside of the high sensitivity is that if you have your prostate removed the PSA becomes a fantastic test. I get it once a year and if it's anything other than zero I know I have a problem
  - NikolaNovak 5y ago
    >> if it's anything other than zero I know I have a problem Is that actually factually always true? At least two of the men I know have had prostate removed and show occasional PSA spikes, that have stumped their doctor for a decade but has never led to any specific issues concerns problems or actions (other than, yes, anxiety...)
    - zwieback 5y ago
      That is concerning. I've heard that PSA can be produced in other parts of your body but at very low level, not enough to pass the threshold of concern. If the spikes are high and the test is reliable then there could be something lurking in the body somewhere. The other answer also suggests it's difficult to diagnose where the cancer (or tumor, etc.) is located.
      - drocer88 5y ago
        Here's an authoritative source on Protein Specific Antigen ( aka KLK3, Kallikrein related peptidase 3 ): https://www.proteinatlas.org/ENSG00000142515-KLK3/tissue https://www.proteinatlas.org/ENSG00000142515-KLK3/tissue
BXLE_1-1-BitIs1 5y ago
I decline PSA tests. That said, there's no family history.
Someone1234 5y ago
This video does a good job also of covering the topic of over-testing/over-treating potential cancer (or creating "Fake Disease" as it terms it): https://www.youtube.com/watch?v=yNzQ_sLGIuA https://www.youtube.com/watch?v=yNzQ_sLGIuA
mcguire 5y ago
I wonder if in the book the author explores the relationship between prostate testing and breast cancer testing. I can (vaguely) remember when the big push for more and more regular of the latter variety---with similar emotional considerations---started, and also when the FDA (?) reduced the amount of testing after a given age (because it empirically did not lead to better outcomes) and caused a significant furor.
captainmuon 5y ago
I think I'm well versed in statistics, but I don't understand the problem. Why not test everybody, and then adjust the threshold of intervention to reduce overall mortality? (Or maximize quality of life * years, or some other metric taking patient well-being into account.)

32 points by anarbadalov 5y ago

The trouble with preventative medicine is that it is creating artificial anxiety on the basis of the possibility of illness. Thus, we the people are constantly in a state of "possible sickness" and instead of thinking of illness as what it has always been (a state of lack of health which manifests in lack of well-being), we are made to think of illness as "having a wrong parameter". The acceptance of mortality (or its lack) is key to this. Or, on the other hand, we can think of health as "public health", and forget about the individual. But I reject this proposition.

pc86 5y ago
I honestly have no idea what you're trying to say. Are you against preventative medicine? Are you against public health initiatives?
- someguydave 5y ago
  I am against preventative medicine in the case where it has not been shown to have benefits worth the costs.
dlisboa 5y ago
We are always possibly sick at all times, getting a test done will not prevent or change that. The fact that we don’t get anxiety daily is because we forget about it and move on with life. But what is worse? Getting anxiety over being sick for a couple days or living in regret because you didn’t get a simple test to discover something potentially treatable early on? If you “accept mortality” in the way you seem to imply then there’s no need to worry about health anyway. Should I just “accept” that if it wasn’t prostate cancer something else would’ve killed me anyway, so why check?
neogodless 5y ago
> The trouble with preventative medicine is that it is creating artificial anxiety on the basis of the possibility of illness The possibility of illness exists with or without preventative medicine. Preventative medicine decreases that possibility, and reduces anxiety. > The acceptance of mortality (or its lack) is key to this. Whether or not you accept mortality has no effect on whether it is a condition we all share. Though it's unclear to me if you wish for everyone to accept mortality, or reject it. > Or, on the other hand, we can think of health as "public health", and forget about the individual. I'm trying not to read something into this, but it's hard not to. In general, health is personal/individual, even if the way it affects you can then affect others. Of course, in the case of infectious disease, individual infection leads to transmission and public spread, so it should be thought of at more than just an individual level. (That isn't really relevant for the PSA, though. That's quite individual.)
xboxnolifes 5y ago
> The trouble with preventative medicine is that it is creating artificial anxiety on the basis of the possibility of illness. I don't see it this way. Regardless of the existence of preventative care, what brings anxiety is the knowledge of the existence of the illness and the possibility of being sick. The preventative care (assuming we mean test/monitoring and not constant medication) is what shows me that the anxiety is unfounded.

taylodl 5y ago

I don't understand this thinking at all. Most prostate cancers are a non-issue if caught and treated early. As my father's doctor told him - prostate cancer, if caught early, is largely a disease you die with, not a disease you die from. The PSA is the best tool we have for early diagnosis and treatment. I have the test done as part of my annual checkup and have done so for the past 15 years. Let me put it this way - it's a heckuva lot less invasive than a colonoscopy!

hef19898 5y ago
And I recommend both! No matter how invasive the test, cancer is worse.
- compiler-guy 5y ago
  Malignant cancer is certainly worse, but many prostate cancers that are exposed by this test are totally benign.
  - hef19898 5y ago
    And not discovering early might very well mean the cancer becomes a lot more serious. Never understood the fear of medical exams.
    - compiler-guy 5y ago
      Over treatment is a real issue and can create more serious issues that the original problem.
- throwawayboise 5y ago
  There absolutely are things worse than cancer.
  - hef19898 5y ago
    Depends on the cancer, doesn't it?

zwieback 5y ago

I'm one data point pro PSA: at 43 I had elevated levels, biopsy, detected cancer, prostatectomy followed by full recovery. I can also attest to the anxiety about the two big Is: incontinence and impotence. Luckily I had a great surgeon who'd done hundreds of prostatectomies and everything turned out well. The urologist who originally treated me gave me one good piece of advice, he said "statistically you're not likely to die of this but the problem with statistics is that they may not apply to you". When the surgeon removed my prostate he said that I would have developed symptoms sooner or later even if it hadn't metastasized.

sethammons 5y ago
> "statistically you're not likely to die of this but the problem with statistics is that they may not apply to you" I like that. A lot. Thanks for the quote.

stevespang 5y ago

Another of these "mindless" ramblings with no firm conclusion on a subject which could be distilled into just a few bullet points for an executive summary

zanethomas 5y ago

I had a positive PSA test 11 years ago. Followed by a confirming biopsy. Followed a couple days later by a robotic surgery. Problem solved, obviously, I'm still here. <g>

AlanYx 5y ago

This article isn't very good IMHO because it focuses on emotional considerations rather than the underlying math. The core problems with the PSA test is that it has relatively low statistical specificity and it hasn't been shown to have any statistically significant effect on mortality in aggregate, and the resulting treatment options do have statistically significant morbidity. Hence all the debate about when, how often, and for whom. All the arguments about increased anxiety are pretty unhelpful and obscure the underlying statistical challenges.

zwieback 5y ago
My understanding was that the article was specifically meant to be about the emotional considerations, which are a result of the statistical challenges. BTW: one flipside of the high sensitivity is that if you have your prostate removed the PSA becomes a fantastic test. I get it once a year and if it's anything other than zero I know I have a problem
- NikolaNovak 5y ago
  >> if it's anything other than zero I know I have a problem Is that actually factually always true? At least two of the men I know have had prostate removed and show occasional PSA spikes, that have stumped their doctor for a decade but has never led to any specific issues concerns problems or actions (other than, yes, anxiety...)
  - zwieback 5y ago
    That is concerning. I've heard that PSA can be produced in other parts of your body but at very low level, not enough to pass the threshold of concern. If the spikes are high and the test is reliable then there could be something lurking in the body somewhere. The other answer also suggests it's difficult to diagnose where the cancer (or tumor, etc.) is located.
    - drocer88 5y ago
      Here's an authoritative source on Protein Specific Antigen ( aka KLK3, Kallikrein related peptidase 3 ): https://www.proteinatlas.org/ENSG00000142515-KLK3/tissue https://www.proteinatlas.org/ENSG00000142515-KLK3/tissue

BXLE_1-1-BitIs1 5y ago

I decline PSA tests. That said, there's no family history.

Someone1234 5y ago

This video does a good job also of covering the topic of over-testing/over-treating potential cancer (or creating "Fake Disease" as it terms it): https://www.youtube.com/watch?v=yNzQ_sLGIuA https://www.youtube.com/watch?v=yNzQ_sLGIuA

mcguire 5y ago

I wonder if in the book the author explores the relationship between prostate testing and breast cancer testing. I can (vaguely) remember when the big push for more and more regular of the latter variety---with similar emotional considerations---started, and also when the FDA (?) reduced the amount of testing after a given age (because it empirically did not lead to better outcomes) and caused a significant furor.

captainmuon 5y ago

I think I'm well versed in statistics, but I don't understand the problem. Why not test everybody, and then adjust the threshold of intervention to reduce overall mortality? (Or maximize quality of life * years, or some other metric taking patient well-being into account.)