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"More men die with prostate cancer, than because of it"

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User
Posted 10 Sep 2024 at 10:27

We've probably all heard that.

https://www.sciencedirect.com/science/article/pii/S2468294220300605

An interesting read, that raises many questions. Including the trade offs of increased PSA screening and over detection and overtreatment.

User
Posted 10 Sep 2024 at 12:41
One thing that has always struck me. I’m 57 and incurable 9 years in. My brother is a doctor and is 59 , and he won’t have a test …….. go figure that !!
User
Posted 10 Sep 2024 at 11:04

Yes this is interesting. What struck me most about this article (apart from the main finding that many men have prostate cancer without ever knowing about it) is the incredibly wide range of estimates. This suggests that the definitions may not be very consistent, and the studies may be of variable quality.

For example, table 4 shows that the average incidence discovered across all studies for men aged 60-69 is 25%. But looking at the individual studies the range extends from 3% in one study to 70% at the other end of the spectrum. I conclude from this that there must still be a wide range of uncertainty about what the true figures are (as in fact is illustrated in Figure 3).

User
Posted 14 Sep 2024 at 10:58

I have not found any research which recommends including rate of increase of PSA into a screening program. I did find research on it which suggests it will pick up disease earlier, but those patients will reach the age related level anyway, and the earlier detection given by monitoring rate of increase of PSA isn't significant in treatment outcomes, but comes with increased screening procedure complexity (maintaining and analysing history).

If you are looking at rate of change, a suggested alert figure I heard was 20% increase in a year. Meaningful rate of change calculations require 3 readings each at least 3 months apart, so you can't actually use just annual readings to get a rate of change figure for one year - that would require 6-monthly testing to get 3 readings in a 1 year timeframe.

User
Posted 14 Sep 2024 at 22:41
Thanks Andy, I am sure you are right that for a screening programme a useful indicator or risk needs to come from a single measurement. To have at least 3 successive PSA readings you need already to be earmarked for monitoring. In Mark's case he has had several PSA tests, so rate of change is informative.

But what it comes down to is that a single PSA measurement is poor as a screening test. Interestingly research looking for better alternatives is in the news today. https://www.theguardian.com/society/2024/sep/14/thousands-take-part-in-prostate-cancer-trial-in-bid-to-revolutionise-detection

User
Posted 18 Sep 2024 at 17:57

Just as a side note to the ‘no testing till showing symptoms ‘ decision. 
I had no symptoms whatsoever and still don’t but I am G9 and now incurable and going through Chemo treatment to help eke out some more time.
If I’d not gone to my GP and had a test 6 1/2 years ago then it’s pretty likely I’d not be here now. 

Phil

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User
Posted 10 Sep 2024 at 11:04

Yes this is interesting. What struck me most about this article (apart from the main finding that many men have prostate cancer without ever knowing about it) is the incredibly wide range of estimates. This suggests that the definitions may not be very consistent, and the studies may be of variable quality.

For example, table 4 shows that the average incidence discovered across all studies for men aged 60-69 is 25%. But looking at the individual studies the range extends from 3% in one study to 70% at the other end of the spectrum. I conclude from this that there must still be a wide range of uncertainty about what the true figures are (as in fact is illustrated in Figure 3).

User
Posted 10 Sep 2024 at 12:41
One thing that has always struck me. I’m 57 and incurable 9 years in. My brother is a doctor and is 59 , and he won’t have a test …….. go figure that !!
User
Posted 10 Sep 2024 at 13:23

Hi Chris.

Perhaps GPs know something we don't. 🤔

User
Posted 10 Sep 2024 at 20:40
Chris J, as far as I can see - and to some extent backed up by this article - there is no point in taking "a test" unless it indicates whether someone is Gleason 6 or higher. PSA doesn't do that, far too many results are in the somewhat high but not excessive range.

Your brother has probably decided he doesn't want to undergo a biopsy when he doesn't have any suggestive symptoms. I hope though that as a doctor he would respond if he experienced a change in urine flow or frequency, and certainly if evidence of incomplete bladder emptying.

User
Posted 11 Sep 2024 at 19:42
User
Posted 12 Sep 2024 at 22:35

The article that @Adrian56 shared struck a chord with me and my current "decision pathway" ahead.

While I know they are the least invasive method, PSA tests just seem to be such a blunt diagnostic that can both vary daily and be affected by so many other factors.

Let me indulge myself by telling you where I am at... I am 49 years old and, back in August 2023, I had a (random) PSA test, suggested by my GP, when I went to see him for lower bowel type symptoms (still not resolved but the GP now thinks IBS).

The PSA test came back as 4.99 - so they suggested an MRI, which suggested something *might* be up. The word they used was "equivocal" from the scans. So a biopsy followed in February and they found Gleason 7 (3+4) - in 4 out of 24 cores (20% G4 pattern, no cribriform pattern - maximum cancer core length 6mm) and Gleason 6 (3+3) in 2 out of 24 cores. So overall that's Gleason 7 (3+4) score (Grade Group 2) at three sites.

Now I have spoken to a few different consultants with lots of letters after their names, as well as reading and researching on what all this means, and it seems that I'm exactly at that possible threshold of over-diagnosis. It is commonly agreed that if this procedure were carried out on a sample of men, then PCa would be found in a % of them (I'm deliberately not stating the numbers as they seem to vary so much in the literature too). Of those that have PCa, many will be completely unaffected by it (as stated by the article shared).

I don't want to downplay the need to detect PCa early - and I may well still find that I'll benefit from being in the system so early - but it really does make you think.

Where am I now? Well back in June (when my PSA was found to be 5.4) I opted to have a repeat PSA in a few months rather than jumping straight to surgery. That time has since passed and I'm looking at a new PSA result of 10.7 - which has me more seriously considering RARP surgery (but not relishing any of the potential consequences). And if it wasn't for that random PSA I would be none the wiser.

\_(ツ)_/¯

 

Edited by member 12 Sep 2024 at 22:41  | Reason: Not specified

User
Posted 13 Sep 2024 at 00:10

At 49 you probably shouldn't hang about especially if you want to see 70. 

User
Posted 13 Sep 2024 at 21:36
Mark1975, while PSA tests are a blunt diagnostic as you put it, rate of change of PSA is pretty informative. A doubling in 12 months means it is decision time.

As you found, scans are often not very informative unless the PSA is already sky high. And because they are so invasive, biopsies need good justification.

User
Posted 14 Sep 2024 at 10:58

I have not found any research which recommends including rate of increase of PSA into a screening program. I did find research on it which suggests it will pick up disease earlier, but those patients will reach the age related level anyway, and the earlier detection given by monitoring rate of increase of PSA isn't significant in treatment outcomes, but comes with increased screening procedure complexity (maintaining and analysing history).

If you are looking at rate of change, a suggested alert figure I heard was 20% increase in a year. Meaningful rate of change calculations require 3 readings each at least 3 months apart, so you can't actually use just annual readings to get a rate of change figure for one year - that would require 6-monthly testing to get 3 readings in a 1 year timeframe.

User
Posted 14 Sep 2024 at 22:41
Thanks Andy, I am sure you are right that for a screening programme a useful indicator or risk needs to come from a single measurement. To have at least 3 successive PSA readings you need already to be earmarked for monitoring. In Mark's case he has had several PSA tests, so rate of change is informative.

But what it comes down to is that a single PSA measurement is poor as a screening test. Interestingly research looking for better alternatives is in the news today. https://www.theguardian.com/society/2024/sep/14/thousands-take-part-in-prostate-cancer-trial-in-bid-to-revolutionise-detection

User
Posted 17 Sep 2024 at 20:53

Not wanting to make this thread all about me but I didn't know where else to post and given I'd explained my history above I thought I'd let you know that I've scheduled a date for surgery. 

I've added my PSA trend into my profile - it has gone up then down then up again, in the last 12 months. It doesn't seem particularly consistent as a trend but the jump feels like a warning I can't ignore. And I'll be getting another PSA test before the surgery date too.

User
Posted 17 Sep 2024 at 21:30

Originally Posted by: Online Community Member

Not wanting to make this thread all about me but I didn't know where else to post and given I'd explained my history above I thought I'd let you know that I've scheduled a date for surgery. 

Hi Mark.

You post where you want mate. You've made a treatment decision, and I wish you and your family well. If you can, please keep us updated with how you get on.

Best of luck. 

Edited by member 17 Sep 2024 at 21:36  | Reason: Punctuation

User
Posted 18 Sep 2024 at 17:57

Just as a side note to the ‘no testing till showing symptoms ‘ decision. 
I had no symptoms whatsoever and still don’t but I am G9 and now incurable and going through Chemo treatment to help eke out some more time.
If I’d not gone to my GP and had a test 6 1/2 years ago then it’s pretty likely I’d not be here now. 

Phil

User
Posted 18 Sep 2024 at 18:17

I really don't get often repeated mantra that most men will die with Prostate Cancer rather because of it. I think a lot of men see this and are blase about the disease. My uncle is in his 80s and has been given weeks to live because of prostate cancer. I used to wonder, whether I made the right decision to opt for surgery due to my continued side effects over 2yrs on. The fact is no one really knows, whether to leave a GL7 alone and just monitor or commence treatment. I belong to a boys group of 40men all over 50, and apart from me no one has Prostate cancer.

User
Posted 18 Sep 2024 at 21:00
Gee Baba, "no one really knows" is true, at least on the individual level. The data comes from studies of large numbers, I think ones looking at postmortems.

I suspect that your 50-something friends will report differently as they get older. From experience of my own social circle (including myself) prostate cancer often surfaces in the sixties and seventies.

User
Posted 20 Sep 2024 at 12:19

Originally Posted by: Online Community Member
Gee Baba, "no one really knows" is true, at least on the individual level. The data comes from studies of large numbers, I think ones looking at postmortems.

I suspect that your 50-something friends will report differently as they get older. From experience of my own social circle (including myself) prostate cancer often surfaces in the sixties and seventies.

 

Thanks for the clarification. I guess when it surfaces in the 60s and 70s, the treatment options are limited.

 
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