I thought August 4th, the day the U.S. Preventive Services Task Force, a government appointed panel, published their rather direct concerns about prostate screening effectiveness on the Annals of Internal Medicine would be a day that would make a difference in men’s lives. I was wrong. Digging a little deeper in the history of PSA and its testing, I was shocked to find out here that the person who published the first paper in 1987 in the New England Journal of Medicine claiming that the test could be used to diagnose early prostate cancer, Dr. Thomas Stamey, said “The PSA era is over in the United States,” back in 2004! That means the person who discovered the PSA protein in 1970 and the person who linked the test to a cancer diagnosis agree of its ineffectiveness. The U.S. Preventive Services Task Force is, in fact, a bit late.
Dr. Stamey said that elevated PSA levels actually reflect a condition called benign prostatic hyperplasia, a harmless increase in prostate size. Since screening is now more common, many cancers are being caught earlier and are usually smaller, not generating enough PSA to be a good indicator of severity. By contrast, he said, the tumors encountered 20 years ago were generally so large that they generated PSA levels high enough to provide a reasonably good measure of cancer severity. So effectiveness of the test has decreased over the years. It made sense before, it doesnt now.
Stamey said prostate cancer is a disease “all men get if we live long enough. All you need is an excuse to biopsy the prostate and you are going to find cancer.” he said: “Almost every man diagnosed with lung cancer dies of lung cancer, but only 226 out of every 100,000 men over the age of 65 dies of prostate cancer,”. So what does the PSA test do best? Indicate the size of the prostate. Apparently that’s it and most doctors know it. Even patients might know it too.
Unfortunately, you might be familiar with the rather horrible chain of events that follow a PSA increase: older men whose PSA levels are just above 2 nanograms per milliliter frequently undergo biopsy to find out if such growth is good or bad, which will almost always find cancer. The doctors probably know about it too, while you might be in shambles wondering if you have cancer or not. These results do not necessarily mean that prostate removal or radiation treatment is required, but it usually follows. It’s the dangerous and baseless nip-it-in-the-bud mentality that lives on despite causing so much suffering. “What we didn’t know in the early years is that benign growth of the prostate is the most common cause of a PSA level between 1 and 10 ng/ml,” he said. Yes, up to 10 nanograms!!!! Most urologists would most likely cut you in half after such reading.
Dr. Stamey said “Our job now is to stop removing every man’s prostate who has prostate cancer,” he also said. “We originally thought we were doing the right thing, but we are now figuring out how we went wrong. Some men need prostate treatment but certainly not all of them.”
To detect prostate cancer Stamey recommends a yearly digital rectal exam for all men over 50. “If a cancer is felt in the prostate during a rectal examination, it is always a significant cancer and certainly needs treatment,” he said. Unfortunately, he added, even large cancers often cannot be felt in rectal exams. Apparently he is working on a different kind of testing in order to be able to get a more precise diagnosis.
So there you have it. PSA doesn’t indicate cancer, 90% of older men have some sort of prostate cancer, a cancer with a low mortality rate even when left untreated. Apparently there is an increasing amount of people that agree there is no need to prod, puncture, poison or remove anything: Richard J. Ablin (the discoverer of PSA), Thomas Stamey (the one who suggested its use), and now the U.S. Preventive Services Task Force (the US government). Maybe doctors should encourage some kind of preventative medicine instead of waiting out until the cancer speaks first. Or maybe they should find out if you have an infection, fungus, or something else that causes your PSA increse rather than just suddenly blaming the cancer that all of us in our older age seem to already have.
I should probably add that a low PSA doesn’t rule out prostate cancer either. Some doctors believe that digital rectal examinations are not necessary with PSA lower than 4 ng/mL which other doctors say it’s a mistake. To make matters worse 19 percent of the prostate cancers are diagnosed during surgery on the side opposite the original prostate abnormality, something called “serendipitous detection”, which proves that your prostate growing doesn’t have to be necessarily a tumor. Bottom line: if your PSA is increasing, it means your prostate is growing, nothing more and nothing less. Stay serene and focus your efforts in finding out EXACTLY WHY and how can you change your lifestyle to stay safe, rather than tugging anything out in the first place. If you are 65 or older, you might even have more reasons to stay serene and enjoy your prostate for many years.
What I didn’t know is that men who have undergone a prostatectomy should continue monitoring their PSA as an indicator of possible residual prostate growths in their bodies, this time entirely cancerous. In fact, a PSA that remains undetectable for 1 year or longer after surgery and then rises slowly suggests a local growth, and a bad one this time. And if a PSA that never becomes undetectable after surgery suddenly climbs rapidly it means there is a distant growth elsewhere, which literally means you might be growing an angry prostate somewhere else! And guess what? Nobody can predict what might happen. Men who thought the PSA nightmare was over after doctors yank their prostate might see it come back with a vengeance.
I certainly hope you got all this information from your doctor before you make any final decisions. Think twice before embarking in a preemtive radical treatment. It might not be as clear as you think. You shouldn’t gamble with your organs so lightly, specially when everything is so confusing. You may want to keep all your organs for now and find another doctor that at least uses integrative and preventative medicine to see if you can change the course of things. Making your body as hostile to cancer as possible is more likely to end up being your best guarantee against unpredictability.
I also found out here about the existence of a group of people fighting against this ineffective screening test and its consequences. They are searching for funding to distribute a documentary they made discussing the embarrassing and humiliating consequences of treatment for prostate cancer. They showed the movie at the Gower Theatre at Paramount Studios this past month. Please contact this blog if you have information about it.
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December 31, 2008 at 12:22 pm
I read your article. I went through a pre-screen in late September. I was referred to someone else that said they also felt a lump. I was sent to the hospital where they took a biopsy and a week later I was told that from 11 biopsis, 3 of them came back positive for prostate cancer. One was 40% and the other two were 10%. My Gleason was: 3+3=6. Detected PSA: 2.6 Clinical State 1 (Tic) . Can you give me any direction with this?
Thanks again,
Tim
March 1, 2009 at 6:39 pm
I am the wife of a man who has prostate cancer and write a blog about this disease for a nonprofit organization (prostatecancerblog.net). I think you are on the right track in writing this, because orthodox medical practitioners don’t always do the right thing, especially with PC patients. I am constantly railing against overtreatment. And I advise men with low-grade PC to avoid invasive treatments at all cost, and also, to take a course of antibiotics before they take any action to rule out infection as a cause of elevated PSA. But I must tell you that this story is much more nuanced than it seems.
I support screening, but only *with proper education*, preferably by a doctor who doesn’t stand to gain, such as a urologic oncologist (because early pts aren’t referred to them). The PSA test absolutelly *does* pick up aggressive cancers, like the one my husband has (diagnosed at 53). In fact, Dr. Stamey, limits his conclusions to men with the lowest PSA levels, 1-10. Men are diagnosed with much higher PSA levels than that (in the 1,000s), and at that stage PSA levels do correlate with disease progression, although it is by no means a perfect measure.
If you cut screening altogether, you are effectively handing a death sentence to these people.
Fully one third of patients diagnosed with PC are *under 65*, so that the death rates Dr. Stamey quotes don’t apply to them. Many men in their 40s and 50s get significant PC and die OF it, not WITH it. (Take a look at prostatecancerinfolink.net’s “Younger Men” group.) And believe me, dying of prostate cancer which has spread to the bones is not the way you want to go (has been voted the worst cancer death).
About the DRE as a diagnostic tool: By the time a man has a palpable growth it will almost certainly be too late to do anything about it.
Incidentally, the USPTSF advice against PC screening was limited to men *over 75*. For younger men they don’t take a position but instead advise the patient to discuss the pros and cons of PSA testing with his doctor.
Finally, there are weak points in Dr. Stamey’s arguments. For example, the doctor does not offer a credible answer to the question of why there has been a significant reduction in prostate mortality since PC screening began. He lamely asserts that, since so many men at risk have already been tested, the worst cancers must have been caught early, before they could kill. This is abject nonsense, because even today, 20 years after the inception of PSA testing, only 50% of men over the recommended age actually get tested. And the rates are even lower among blacks, who are more susceptible.
Your heart is in the right place, and I agree with you 100% that men should not “gamble with their organs” (thanks for the line). Treatments for PC can indeed be brutal, and if you have buyer’s remorse you’re out of luck.
We have a shared goal, so do take a look at my blog.
Leah F. Cohen
“Living With Prostate Cancer”
prostatecancerblog.net
A project of Malecare
April 24, 2009 at 2:56 am
This is very up-to-date information. I think I’ll share it on Digg.