To test or not to test … that IS the question!


The “New” Prostate Cancer InfoLink has been at pains over the past few years to distinguish clearly between the use of PSA tests (and now other tests that are slightly more sophisticated) to test individual patients at a point in time and the use of the PSA test in annual, mass screenings for risk of prostate cancer. We are very clear in our own mind that the former is a good idea and that the latter is much less wise.

A recently published article by Wibowo et al. (“Should I get a PSA test?” – the question is not that simple), in Trends in Urology and Men’s Health, arguably helps to put this distinction in even greater perspective for the individual patient because it is highly focused not on the test itself but on the potential consequences of such a test — especially in the case of men who are liable to have a high level of anxiety about the consequences of the test result.

Now we should note immediately that we are aware that at least three of the authors of this article have actually been diagnosed with prostate cancer and have stated so publicly (and two of these three authors are also urologic oncologists), so they may have a degree of strong personal opinion on the topic of PSA testing (but that doesn’t necessarily make them wrong in their opinions). Four of the total of six authors are, in fact, well-known and respected urologic oncologists. Your sitemaster would also note that while he does not personally believe in annual, mass “screening” of all men over (say) 50 years of age, he does believe in the careful use of PSA testing to assess potential risk over time.

Given those contextual disclaimers, The “New” Prostate Cancer InfoLink thinks that this article by Wibowo et al. offers a very useful way for the individual man (and his doctors) to look at the question of whether he should or shouldn’t have a PSA test at any particular point in time, taking into consideration  such factors as the following:

  • Our individual life expectancies
  • Our knowledge that a PSA test conducted in one’s 40s can offer useful information about long-term risk for prostate cancer (over something like the next 25 years)
  • Whether an individual patient does or does not have any significant, known familial, genetic, ethnic, or other known risk for prostate cancer
  • Our individual attitudes to health risk and how well we handle such information and the actual risks themselves
  • Our individual perspectives on how we would handle
    • The potential need for a prostate biopsy and the risks associated with such a biopsy
    • The actual diagnosis of prostate cancer and the potential need for treatment of such prostate cancer
    • A diagnosis of low- or very low-risk prostate cancer that is probably indolent and that could be just “lived with” for years (or even for ever)

Wibowo et al. are certainly correct in their estimation that whether or not one should have a PSA test is not a simple question. However, whether one should or should not get a PSA test at a specific point in time is also not amenable to a simple, dichotomous, “Yes/No” answer that can be applied to all men. It will inevitably depend on a wide variety of other factors.

To give an entirely personal perspective on this, your sitemaster, at 67 years of age, in pretty good health (all things considered), with a 200-year history of men in his family living well into their 90s, and with a very limited familial history of cancer of any type at all (and none at all of prostate cancer specifically) is unlikely to ever actually ask for another PSA test … but he will certainly continue to have DREs on an annual basis, and he would certainly consider having another PSA test if there was any evident clinical reason to do that.

In general, he considers his likelihood of diagnosis with clinically significant prostate cancer to be so low that annual PSA tests are simply an invitation to find a form of prostate cancer that would be most unlikely to ever need treatment that would extend his survival. However, if his father had been diagnosed with prostate cancer when in his late 60s or early 70s, and then died of this disease, your sitemaster is also very conscious that he would, entirely reasonably, have a very different perspective.

Editorial comment: We thank one of our regular correspondents for bringing this article by Wibowo et al. to our attention.

12 Responses

  1. Thanks to the “regular correspondent” who found this article and to Sitemaster for reviewing it. (And Sitemaster’s approach to his own situation makes sense to me.) This article strikes me as useful for helping educate education and support group members in their work to help newly diagnosed men and in their outreach efforts to advocate smart screening. My own approach in discussing screening is along the same lines, but with a different priority, and a different conclusion regarding the anxious minority who are uncomfortable with the prospect of active surveillance.

    Rather than assess up front where a man (or spouse) feels about risks of biopsy, diagnosis, and dealing with cancer, we should first communicate that active surveillance has proven highly successful in managing low-risk prostate cancer. We should provide some key facts that make that point, emphasizing the firm foundation in research. A key next step is assessing whether the person is now comfortable with the prospect of a diagnosis of low-risk prostate cancer that can be managed with active surveillance. If yes, then screening is a usually a good choice, and subsequent discussion can dot the i’s and cross the t’s to make sure (such as ruling out short life-expectancy issues).

    On the other hand, if the patient is anxious and clearly balking when presented the information about active surveillance, then he has a greatly elevated risk of over-treatment, and the subsequent discussion should bring out the risks of missing serious disease if he does not get screened versus the consequences of unnecessary treatment if he does get screened. To me, such men face a tough decision. I am personally comfortable laying out the real facts to such men, but I’m not comfortable pushing them toward screening. By “real facts” I don’t mean the horribly mangled version that emerged from the US Preventive Services Task Force, a version that still today seems to dominate their thinking. For instance, the Task Force was oblivious to critical shortfalls in the research upon which it relied, and it has remained oblivious to the sharp improvement in the benefit of screening as the European trial has added even a few years of follow-up.

    I especially liked the following line from the paper: “Simply stated, the USPSTF did not consider the adaptability of men diagnosed with prostate cancer.” We are now in position to make good use of that adaptability.

  2. Super nice essay and super quick too. Thanks!

    I hope you manage to live at least as long as your male ancestors. My personal interest in prostate cancer is also somewhat motivated by my own family’s history of longevity. My Dad had prostate cancer and died some months after being treated for urethral obstruction from advanced prostate cancer that he refused to get treated when first diagnosed. So I want to outlive him.

    For the record he died at 98.

    :-)

    Richard W.

  3. Important is educating family physicians that PSA testing accompanied by DRE continue to be important for men entering the age level wherein at least the PSA level provides a base marker from which to compare future PSA results; and the DRE similarly to rule out the presence of prostate cancer development. Until we overcome the inadequate and totally wrong conclusions of the USPSTF, we will continue to see men arriving at urology facilities with prostate cancer in advanced development rather than being able to nip early developing prostate cancer in the bud.

  4. Well put, Sitemaster and JW. What irks (and concerns) me is the fact that the test/no test controversy has unfortunately affected men like me who have already had a prostate cancer diagnosis, and perhaps a round of treatment, and now find themselves pleading for “extra” PSA follow-up testing, i.e., something more than twice per year. In my case, a wildly fluctuating PSA in the double digit range seems a good argument for quarterly testing at a minimum. I can think of no reason my urologist resists other than contemporary prostate politics, sad to say.

  5. Dear Rob:

    Yours appears to be a very different situation and actually I don’t think it has anything to do with the test/no test controversy. It may also depend on a whole bunch of other factors (e.g., your treatment). However, one option that may or may not be available to you would be to switch urologists.

  6. Regarding Rob’s experience, I think the USPSTF recommendations have no relevance to a patient who has actually been diagnosed with prostate cancer. As a 5-year prostate cancer “survivor” (Gleason 9, Hopkins IMRT, 2-year ADT) I can and do get PSA tests whenever I want to. I believe the “one per year” criterion is specifically geared to screening prior to any prostate cancer diagnosis, and post-treatment PSA tests are coded, treated by insurers, and billed quite differently. Or maybe my PCP, urologist and radiation oncologist are just very nice. (Actually they are, anyway).

  7. Late to the party ….. but I have a very pertinent observation. The PSA test is about information NOT treatment,

    If the information is appropriately processed by both patient, his medical team and other advisors, there should be no risk of over-treatment … or even anxiety, Now, Sitemaster, I accept this a huge “if” and that the financial bias of the way medicine is practiced in this country makes it very difficult to assure unbiased processing.

    I do hold that mass testing is appropriate if we can separate the information from the treatment advice. And I do believe there are sufficient men who have no family history, no significant risk factors, or who have no markers from their 40s, that unexpectedly fall to our disease. With annual PSA tests for all from at least 50 — and earlier for some — fewer fatal outcomes could be achieved while avoiding over-treatment.

    Sitemaster and I have long respectfully differed over this issue — but what it raises is the need for much greater emphasis on awareness, education … and ethics!

    As to the absolutely ‘criminal’ USPSTF recommendations, I would not be surprised if PCa deaths surpass BCa within the next 3-5 years.

  8. And for new readers, the reason that Rick and I disagree is that I think (respectfully) that he is living in Dreamland on this topic and that the real area of emphasis should be on finding a much more effective and accurate test that really can be used to screen men with a high level of accuracy for risk of clinically significant prostate cancer.

    :O)

  9. I don’t disagree on the need for a better test …. but in the meantime?

    I may disagree on Dreamland — even if I do have Great Ormond Street to thank for being around long enough to get prostate cancer!

  10. Now there’s an allusion that will escape the vast majority of readers of this site!

    :O)

  11. Discouraging on Sirius/XM Doctor’s channel

    I happened to catch a brief exchange on this channel about 6:20 PM EST, one that I catch only occasionally. Most unfortunately, the doctor interviewed bought the recommendation of the blundering USPSTF hook, line and sinker — complete acceptance with no awareness of the profound flaws in their approach. Basically, he echoed their recommendation not to screen “except in high risk cases” (his words).

  12. Jim

    I suggest you reach out to the channel and ask them to give equal time to either or both a patient advocate and/or a qualified prostate cancer physician. I am sure I can set up a doctor from UCSF — Mack Roach or Peter Carroll or Matt Cooperberg.

    Let us know.

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