Incidentally, on a non cancer forum, where I am a member, the subject of PCA Screening was raised. I learnt something and thought I would post comments of one of the members. I have made a few redactions mainly to protect member's identity and to remove my posts.
' The PSA test on the other hand is no longer recommended as a screening test. Hasn't been for 2 years now. I should know, I teach this to med students. See: https://view-health-screening-recommendations.service.gov.uk/prostate-cancer/
A digit rectal exam on the other hand, no pun intended, is valuable. You don't need to reach the whole prostate. The vast majority of prostate cancers originate in the peripheral zone (PZ in below image), that's what you can feel through the rectum. Also, with proper training it is anything but subjective. It's the difference between poking the muscle at the base of your thumb to poking your knuckle when it comes to hardness, rubbery vs hard. Not to mention smooth (normal) vs bumpy/craggy (not normal). That being said mutiparametric tests are being evaluated that include imaging (e.g.MRI) along with a cancer marker (blood) test. None have reached the numbers required for a solid conclusion. Now the reason we worry about PZ cancers is that they do not have early warning signs. Hence, the need to screen. While the other zones are wrapped closer around the urethra, they will announce themselves earlier with symptoms similar to benign prostate hyperplasia (hard to start a stream, hard to stop, dribbling...etc.). Bottom line, again pun not intended, don't ignore your DREs
I talked about the zones, and specifically mentioned the symptoms of cancer arising in those zones not detected by a DRE. The urethral symptoms will give warning. Your link says the same thing but with less of medical explanation. Also, those cases of GP vs urologist, again see above when I said with proper training. I've had the misfortune of dealing with GPs who were as xxxxxxxxxxxxxxx. A urologist would have proper training, one would hope. Just an FYI there is no such thing as a 100% accurate test. You take the best combination of sensitivity, specificity, positive and negative predictive values that you can get. For example, a PSA test was thought to be good enough until it turned out to be not sensitive enough (missing too many cases, i.e. false negatives), not specific enough (ejaculating, riding a bicycle, having a DRE or an infection are all things amongst a host of other non-cancer related things that can elevate your PSA, so massive over-diagnosis i.e. false positives), but good enough to follow a case post diagnosis/treatment after you have established a personalized baseline. You see a screening test needs to be sensitive enough to catch most cases (notice I said most, not all), without over-diagnosing cases that don't need to be treated or non-cancer cases. The PSA failed on both accounts. Currently, the DRE is the only thing that even comes close to fitting that description until studies on the newer diagnostic modalities provide statistical evidence. What you're quoting in that link sadly is medical legalese. They are covering their collective behinds as well as informing you, that a negative test does not mean you are cancer free, and if you read the whole thing, a positive test means we need to investigate further. It's the same warning on every single test. So if you do end up having cancer, "but the test was negative doc" "yeah, but we told you...". See where I'm going with this? This is my bread and butter speciality. I'm an MD/PhD in oncological sciences, researching and teaching this stuff for a couple of decades plus. ….......'
Edited by moderator 27 Aug 2022 at 23:03
| Reason: To paragraph for easier reading.
Barry |
User
Incidentally, on a non cancer forum, where I am a member, the subject of PCA Screening was raised. I learnt something and thought I would post comments of one of the members. I have made a few redactions mainly to protect member's identity and to remove my posts.
' The PSA test on the other hand is no longer recommended as a screening test. Hasn't been for 2 years now. I should know, I teach this to med students. See: https://view-health-screening-recommendations.service.gov.uk/prostate-cancer/
A digit rectal exam on the other hand, no pun intended, is valuable. You don't need to reach the whole prostate. The vast majority of prostate cancers originate in the peripheral zone (PZ in below image), that's what you can feel through the rectum. Also, with proper training it is anything but subjective. It's the difference between poking the muscle at the base of your thumb to poking your knuckle when it comes to hardness, rubbery vs hard. Not to mention smooth (normal) vs bumpy/craggy (not normal). That being said mutiparametric tests are being evaluated that include imaging (e.g.MRI) along with a cancer marker (blood) test. None have reached the numbers required for a solid conclusion. Now the reason we worry about PZ cancers is that they do not have early warning signs. Hence, the need to screen. While the other zones are wrapped closer around the urethra, they will announce themselves earlier with symptoms similar to benign prostate hyperplasia (hard to start a stream, hard to stop, dribbling...etc.). Bottom line, again pun not intended, don't ignore your DREs
I talked about the zones, and specifically mentioned the symptoms of cancer arising in those zones not detected by a DRE. The urethral symptoms will give warning. Your link says the same thing but with less of medical explanation. Also, those cases of GP vs urologist, again see above when I said with proper training. I've had the misfortune of dealing with GPs who were as xxxxxxxxxxxxxxx. A urologist would have proper training, one would hope. Just an FYI there is no such thing as a 100% accurate test. You take the best combination of sensitivity, specificity, positive and negative predictive values that you can get. For example, a PSA test was thought to be good enough until it turned out to be not sensitive enough (missing too many cases, i.e. false negatives), not specific enough (ejaculating, riding a bicycle, having a DRE or an infection are all things amongst a host of other non-cancer related things that can elevate your PSA, so massive over-diagnosis i.e. false positives), but good enough to follow a case post diagnosis/treatment after you have established a personalized baseline. You see a screening test needs to be sensitive enough to catch most cases (notice I said most, not all), without over-diagnosing cases that don't need to be treated or non-cancer cases. The PSA failed on both accounts. Currently, the DRE is the only thing that even comes close to fitting that description until studies on the newer diagnostic modalities provide statistical evidence. What you're quoting in that link sadly is medical legalese. They are covering their collective behinds as well as informing you, that a negative test does not mean you are cancer free, and if you read the whole thing, a positive test means we need to investigate further. It's the same warning on every single test. So if you do end up having cancer, "but the test was negative doc" "yeah, but we told you...". See where I'm going with this? This is my bread and butter speciality. I'm an MD/PhD in oncological sciences, researching and teaching this stuff for a couple of decades plus. ….......'
Edited by moderator 27 Aug 2022 at 23:03
| Reason: To paragraph for easier reading.
Barry |
User
They don't use it for prostate cancer staging and risk though - they use it simply as one marker in some guesswork about whether an MRI scan and biopsy might be a worthwhile use of NHS money.
You could have had that PSA reading and had no cancer at all, just a large prostate. Si_Ness with his PSA of 3 and widespread mets would never even have been referred!
Edited by member 07 Sep 2022 at 14:00
| Reason: Not specified
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
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User
Treatments for PCa have been improved and additional ones trialled but by comparison very limited progress made in easily and cheaply determining who has PCa and moreover those who really need early treatment. The PCA3 test was at one time suggested as a way to help identify PCa, particularly used in conjunction with PSA but you hardly find it mentioned these days. Genetic tests can suggest men that are more susceptible to having PCa and we know some categories of men that are more at risk but we seem to be some way off easily and accurately identifying men more definitively with PCa and those who need early treatment which is the other prime consideration.
Barry |
User
Originally Posted by: Online Community MemberLynEyre -
This is what I was referring to when I spoke about risk. PSA > 20 is always seen as high risk according to these guidelines. I wonder if you couldn't at least screen out the intermediate (PSA>10) and high risk cases (PSA >20) with other high PSA less than 10 tracked over time. Also I think younger men (40s/50s) should be screened as the impacts on younger men are particularly devastating. But there is a general sense that this is an old man's disease so younger men don't have to be concerned. But in reality we will probably have to wait for a better test for widespread screening.
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There are 3 general risk groups based on the PSA, DRE, and biopsy, which can further be subdivided to better personalize treatment for each patient.
- Low risk: Tumor is confined to the prostate, and the PSA is <10 and grade group 1 (Gleason 6). There is also a subset of extremely “slow-growing” tumors called “very low risk” in which fewer than 3 biopsy tissue samples contain cancer cells and the cancer is not detectable by DRE.
- Intermediate risk: Tumor is confined to the prostate, the PSA is between 10 and 20, or grade group 2 or 3 (Gleason 7). This category is often divided into a “favorable” and “unfavorable” intermediate risk.
- High risk: Tumor extends outside the prostate, the PSA >20, or grade group 4 or 5 (Gleason 8 to 10). There is also a subset of very aggressive tumors is called “very high risk” in which the tumor has extended into the seminal vesicles (T3b) or the rectum or bladder (T4), or there are multiple biopsy samples with high grade cancer.
That risk register is based on having already been diagnosed and knowing what the Gleason score and grading is. You can't apply the same principle to men who have not yet had a biopsy because he may have a PSA of 3 but a Gleason of 10 and a staging of T3 or T4 and mets to lymph, bone and / or organs
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
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User
Mine too. Moderately high psa, DRE detected nothing, initial MRI inconclusive. If it hadn't been for blood in my urine there wouldn't have been any action. [PSA was 11, G9 with nearby mets.]
Jules
Edited by member 09 Sep 2022 at 05:20
| Reason: Not specified
User
Originally Posted by: Online Community MemberThis information isn't new. The NSC has never recommended prostate screening.
What is quite new is an increasing recognition that prostate cancer has no symptoms until incurable, and that the classic LUTS (urgency, peeing many times at night, slow flow, etc) are nothing to do with prostate cancer, and it may even be the case that men with none of these symptoms (and hence less likely to have an enlarged prostate) may even be at slightly higher risk of prostate cancer than those with LUTS.
My father had LUTS many years before being diagnosed (always put down to getting old when he was in his in late 50s!). He was dead from PC 3 years after diagnosis at 69.
The PC treatment (RT and HT) cured his LUTS but obviously not his cancer.
Do not ignore any symptoms! Do not ignore a raised PSA!
Most of all do not listen to GP's
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Bumping this missed post.
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User
The thing I can't get my head around with this is that in January my GP did a PSA test and rang me very concerned because the reading was 76.
Despite not knowing anything about PSA I was able to do a Google search and figure out pretty quickly that most likely I had prostate cancer with a high risk of advanced cancer. The first consultant Urologist I went to sent me for all the scans with the note "probable metastatic cancer". As it turned out, unfortunately I do have advanced cancer with likely distant lymph node involvement from PSMA scan (biopsy next week to confirm).
So on one hand the medical profession are saying the test is not accurate enough for screening and on the other hand they use it for prostate cancer staging and risk evaluation. Which is it?
User
They don't use it for prostate cancer staging and risk though - they use it simply as one marker in some guesswork about whether an MRI scan and biopsy might be a worthwhile use of NHS money.
You could have had that PSA reading and had no cancer at all, just a large prostate. Si_Ness with his PSA of 3 and widespread mets would never even have been referred!
Edited by member 07 Sep 2022 at 14:00
| Reason: Not specified
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
|
User
Treatments for PCa have been improved and additional ones trialled but by comparison very limited progress made in easily and cheaply determining who has PCa and moreover those who really need early treatment. The PCA3 test was at one time suggested as a way to help identify PCa, particularly used in conjunction with PSA but you hardly find it mentioned these days. Genetic tests can suggest men that are more susceptible to having PCa and we know some categories of men that are more at risk but we seem to be some way off easily and accurately identifying men more definitively with PCa and those who need early treatment which is the other prime consideration.
Barry |
User
LynEyre -
This is what I was referring to when I spoke about risk. PSA > 20 is always seen as high risk according to these guidelines. I wonder if you couldn't at least screen out the intermediate (PSA>10) and high risk cases (PSA >20) with other high PSA less than 10 tracked over time. Also I think younger men (40s/50s) should be screened as the impacts on younger men are particularly devastating. But there is a general sense that this is an old man's disease so younger men don't have to be concerned. But in reality we will probably have to wait for a better test for widespread screening.
----------
There are 3 general risk groups based on the PSA, DRE, and biopsy, which can further be subdivided to better personalize treatment for each patient.
- Low risk: Tumor is confined to the prostate, and the PSA is <10 and grade group 1 (Gleason 6). There is also a subset of extremely “slow-growing” tumors called “very low risk” in which fewer than 3 biopsy tissue samples contain cancer cells and the cancer is not detectable by DRE.
- Intermediate risk: Tumor is confined to the prostate, the PSA is between 10 and 20, or grade group 2 or 3 (Gleason 7). This category is often divided into a “favorable” and “unfavorable” intermediate risk.
- High risk: Tumor extends outside the prostate, the PSA >20, or grade group 4 or 5 (Gleason 8 to 10). There is also a subset of very aggressive tumors is called “very high risk” in which the tumor has extended into the seminal vesicles (T3b) or the rectum or bladder (T4), or there are multiple biopsy samples with high grade cancer.
User
This information isn't new. The NSC has never recommended prostate screening.
What is quite new is an increasing recognition that prostate cancer has no symptoms until incurable, and that the classic LUTS (urgency, peeing many times at night, slow flow, etc) are nothing to do with prostate cancer, and it may even be the case that men with none of these symptoms (and hence less likely to have an enlarged prostate) may even be at slightly higher risk of prostate cancer than those with LUTS.
User
A DRE detected mine although I was told it was hard, not nobbly. I suspect a nobbly one isn't good news.
They say the condition develops slowly and that most die with it not of it. Although some 12,000 a year die of it even if it takes a long time to die. Also you might hope that newer treatments will cause that number to reduce.
Screening sounds a good thing and perhaps a stronger push for DRE testing would find enough to make a difference if it's right that a hard prostate is a more significant symptom than a high psa.
A problem is that once you start on the treadmill of treatments it's hard to know when to get off and your life may never be quite the same even if you don't have PCa.
Some data would be useful as we don't know how many have high psa and don't have PCa or how many have hard prostates etc.
User
Mine was detected by high PSA and biopsy. The DRE and MRI were inconclusive. Just shows how it varies between individual cases. Personally I hate the phrase "most men die with it not of it" as it lends iteself to complacency. If you get prostate cancer in your 50s and do not get it treated there is a significant chance you will die of prostate cancer (and even if it is treated significant chance of recurrence). We are also given the impression that this is an older man's disease but the consequences of getting it when you are younger are potentially a lot more severe in terms of lifespan and QoL.
User
Originally Posted by: Online Community MemberLynEyre -
This is what I was referring to when I spoke about risk. PSA > 20 is always seen as high risk according to these guidelines. I wonder if you couldn't at least screen out the intermediate (PSA>10) and high risk cases (PSA >20) with other high PSA less than 10 tracked over time. Also I think younger men (40s/50s) should be screened as the impacts on younger men are particularly devastating. But there is a general sense that this is an old man's disease so younger men don't have to be concerned. But in reality we will probably have to wait for a better test for widespread screening.
----------
There are 3 general risk groups based on the PSA, DRE, and biopsy, which can further be subdivided to better personalize treatment for each patient.
- Low risk: Tumor is confined to the prostate, and the PSA is <10 and grade group 1 (Gleason 6). There is also a subset of extremely “slow-growing” tumors called “very low risk” in which fewer than 3 biopsy tissue samples contain cancer cells and the cancer is not detectable by DRE.
- Intermediate risk: Tumor is confined to the prostate, the PSA is between 10 and 20, or grade group 2 or 3 (Gleason 7). This category is often divided into a “favorable” and “unfavorable” intermediate risk.
- High risk: Tumor extends outside the prostate, the PSA >20, or grade group 4 or 5 (Gleason 8 to 10). There is also a subset of very aggressive tumors is called “very high risk” in which the tumor has extended into the seminal vesicles (T3b) or the rectum or bladder (T4), or there are multiple biopsy samples with high grade cancer.
That risk register is based on having already been diagnosed and knowing what the Gleason score and grading is. You can't apply the same principle to men who have not yet had a biopsy because he may have a PSA of 3 but a Gleason of 10 and a staging of T3 or T4 and mets to lymph, bone and / or organs
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
|
User
Mine too. Moderately high psa, DRE detected nothing, initial MRI inconclusive. If it hadn't been for blood in my urine there wouldn't have been any action. [PSA was 11, G9 with nearby mets.]
Jules
Edited by member 09 Sep 2022 at 05:20
| Reason: Not specified
User
Originally Posted by: Online Community MemberThis information isn't new. The NSC has never recommended prostate screening.
What is quite new is an increasing recognition that prostate cancer has no symptoms until incurable, and that the classic LUTS (urgency, peeing many times at night, slow flow, etc) are nothing to do with prostate cancer, and it may even be the case that men with none of these symptoms (and hence less likely to have an enlarged prostate) may even be at slightly higher risk of prostate cancer than those with LUTS.
My father had LUTS many years before being diagnosed (always put down to getting old when he was in his in late 50s!). He was dead from PC 3 years after diagnosis at 69.
The PC treatment (RT and HT) cured his LUTS but obviously not his cancer.
Do not ignore any symptoms! Do not ignore a raised PSA!
Most of all do not listen to GP's
User
I had classic LUTS and repeat UTI's that led to a PSA test.. followed by the usual DRE, scans, and biopsy to my cancer diagnosis.
As above, don't ignore symptoms.