Prostate Cancer

Thanks, Bill. I totally agree that an annual PSA check is a great idea.

One issue is that GP surgeries have a threshold set (usually around 5) where the system flags it up. Below that level, it flies under the radar, and nobody takes any notice.

But, it's the rate of increase that matters more than the absolute level. So, keep an eye on the rate of increase, and discuss it with your doctor if it increases more rapidly than usual.

My best friend is having to have some serious treatment this month for prostate cancer. His level had been stable at around 0.2 for years, Then, at the beginning of the pandemic, it increased to 1. The following year it increased to 2. He's kicking himself for not reacting on the first increase.

Thinking of you. Hope you manage to sort it out.

Hang on in there.

Dave R

Good to hear it seems now to be ok.

Thankfully I have a low PSA but also conscious it can change. It is shameful it's something I've had to ask for.

It?s a popular misconception that if a bit of screening is good, more screening is automatically better.

All screening needs to be targeted to avoid doing more harm than good. That said, thresholds for screening aren?t consistent nationwide and it may be that you?re in a health authority area that that has a lower level of screening than might be considered optimal in another area.

Tim

You seem to be almost a lone voice in the wilderness. Let me add mine to balance the feeling here that "you must get tested". I did the check at

So I had a search for more balanced information, and found this page from the US:

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The United States Preventive Services Task Force has analyzed the data from all reported prostate cancer screening trials, principally from the PLCO and ERSPC trials, and estimated that, for every 1,000 men ages 55 to 69 years who are screened every 1 to 4 years for 10 to 15 years (7):

About 1 death from prostate cancer would be avoided. 120 men would have a false-positive test result that leads to a biopsy, and some men who get a biopsy would experience at least moderately bothersome symptoms from the biopsy. 100 men would be diagnosed with prostate cancer. Of those, 80 would be treated (either immediately or after a period of active surveillance) with surgery or radiation. At least 60 of these men would have a serious complication from treatment, such as erectile dysfunction and/or urinary incontinence.

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GB expressed precisely :

My most recent result was 5.5, which would have raised no concerns under the old limit, but did because it was higher than new 2.9 limit. After a bit of discussion, I managed to convince the doc, that there was nothing to be overly concerned about.

Harry Bloomfield Esq presented the following explanation :

I should point out, that I have never requested any tests at all, not even the PSA level check. They initially found my PSA level high, during blood sampling for other reasons.

In message snipped-for-privacy@mid.individual.net>, at 15:12:01 on Fri, 11 Mar 2022, williamwright snipped-for-privacy@f2s.com remarked:

I thought PSA was a test for the reaction of a prostate gland to becoming clogged up. If you don't have one at all, where is the PSA coming from?

So I had a search for more balanced information, and found this page

snip

Yes, but I purposely left out any selective quote as it is the *whole* article which should be read.

The NICE guidelines for 2-week cancer referral to urology are:

Below 40 Use clinical judgement

Individual NHS regions can set their own levels. Some GP's set their levels in conjunction with their local urology consultants, and one I know uses 3 up to age 70, and 4 above age 70. I've also come across another area which won't do PSA tests above age 70, which all the clinicians I've spoken with consider to be very wrong.

It isn't always recommended to have a PSA test annually. There's been a lot of research on this in Europe, and the testing frequency is based on how close you are to the threshold, going up to 3 years (I think) if you are a long way below the threshold. One interesting data point in their recommendations is that if your PSA is <1 at age 60, there's so little chance of you ever getting significant prostate cancer that no further PSA testing is required, and that accounts for 1/3rd of all men.

PSA tests are very cheap if they're added on to another blood test which is being done anyway and requires a yellow blood tube (the most common type), so doing this occasionally should be a no-brainer. They're more expensive if done by themselves.

That's really important. An increase of 20% in a year regardless of level should result in a 2-week referral, although that's not in the guidelines. At levels close to the thresholds, PSA test should be repeated in 6-12 weeks, and a referral made in the case of a significant increase.

Plotting a series of tests over years is a much better indication of any problem than a single PSA result, but GP's generally don't have the knowledge in this area to know how to interpret this.

There is a massive problem in primary care that a large proportion of GP's either know very little about prostates, or they're way out of date on the prostate cancer diagnosis pathway and think that over-treatment is still at the level it was 15 years ago. This isn't the case. Over-treatment is currently 4%-5%, but late treatment (no longer confined to prostate) is running at almost 50%, which includes the ~20% of men already incurable at diagnosis. Several urology departments spend effort trying to educate GP's in their area to refer earlier, while patients still have a good chance of being cured with minimal side effects.

That is sadly all too common, together with men diagnosed as incurable who had PSA levels where they should have been referred for a decade before, but the GP failed to do so.

PSA and other aspects of prostate cancer is an area where the patient really needs to understand what's expected, because the level of knowledge in primary care is generally too low. This applies after treatment too.

Cheers Andrew

Healthcare motivations in the US are very different from most other places in the world. Most of the US still hasn't implemented mpMRI scan before biopsy, because their insurance companies won't pay for it, and that's a significant factor in reducing over-diagnosis (why would you want to do that when you are paid for treatments?). Treatments offered in the US are slightly different as they don't need to go through the same rigorous trials to prove their efficacy that they do in most of the rest of the world. A reduction in PSA screening in the US around 8 years ago has resulted in an increase in the number of men diagnosed later stage 4 (incurable) now.

I have sat in on a couple of US support groups, and at least we don't have the risk of going bankrupt and losing our house because of a cancer diagnosis, or spend weeks trying to get insurance companies to change their minds when they refuse a procedure or medication the consultant wants to use. Also, most of their drugs cost way more than the NHS buys them for here. Hormone therapy drugs (important for many patients) are

I'm very grateful to have gone through my prostate cancer treatment without have been given a single bill or having lost my house.

Andrew

PSA test isn't related to prostate gland getting clogged up (prostatitis), but measures how much PSA is leaking into the blood (where is isn't meant to go) due to disorganised or damaged prostate cells. Prostatitis is another possible cause of raised PSA if there's any infection associated.

Significant or increasing levels of PSA after prostatectomy is due either to some prostate cells being left behind at the site of the prostate (prostate bed) which may or may not be cancerous (depending if the PSA increases), or some cancer cells had already left the prostate and formed metastasis elsewhere.

Sadly, around 30% of prostatectomies fail for this reason, and then further treatment will be required. If you're lucky, you might still have curative treatment options (cells left in the prostate bed are usually amenable to radiotherapy).

Andrew

That isn't necessarily the right advice with those over 70 because very few of those are killed by prostate cancer, they die of something else, often with very slow developing prostate cancer.

The reality is that mos't arent killed by their prostate cancer, they die with their prostate cancer of something else. That's why some don't bother with PSA tests when over 70, so that isn't very wrong.

It may be that mpMRI is the "gold standard", but it has to be done right or it may give misleading results

There appear to be differences in the approach between Europe and North America (and even within North America) to using mpMRI before biopsy. From

"Not surprisingly, guidelines from expert groups are variable:

?Updated guidelines for prostate cancer diagnosis and management from the United Kingdom National Institute for Health and Care Excellence (NICE) suggest offering multiparametric MRI as the first-line investigation for all people with suspected clinically localized prostate cancer.

?National Comprehensive Cancer Network (NCCN) guidelines recommend consideration of MRI, but they do not provide any guidelines for selecting appropriate candidates.

?American Urological Association (AUA) guidelines state that there are insufficient data to recommend routine MRI in every biopsy-naïve patient under consideration for prostate biopsy. Its use may be considered in males for whom the clinical indications for biopsy are uncertain (minimal PSA increase, abnormal digital rectal examination [DRE] with normal PSA, or very young or old patients).

?Updated year 2019 guidelines from the European Association of Urology (EAU) endorse MRI prior to initial biopsy.

?Guidelines from Cancer Care Ontario (CCO) do not advocate MRI prior to initial TRUS-guided biopsy."

Treatments offered

Where did you get that from? Do you think that all the 3000+ prostate cancer trials listed here are unapproved or have just cursory approval?

In any case, the US is so litigious that no doctor in his right mind would risk using or trying something unapproved.

. A reduction in PSA screening in the US around 8 years

There's nothing specific to prostate cancer there, as all medical treatment in the USA is expensive. But we aren't discussing treatment, we are discussing diagnosis. That, of course, also has to be paid for. I don't like the system, but that's the way it works. Also, many drugs are available earlier in the US because /someone/ will pay for the treatment. Over here, particularly if the drug is ultra-expensive, you'd have to wait for NICE to approve it for use on the NHS before it became available, and that can add months.

You'd already paid for it through your NI contributions over the years. NI is very little different in its way from any insurance policy. You pay a premium up front, and if you have to claim you get the cost back in one way or another. Those who stay healthy through their life lose the most, but somehow I reckon they'd happily accept that rather than have one or more illnesses which severely affect their quality of life.

Like Covid because of the cancer suppreesing drugs/

I've known three people die of prostate cancer. Two were over 70.

I only knew one - my father - he was 89.

Even when detected, they normally won't give you the cancer suppressing drugs unless your cancer is a faster growing one and does risk ending your life early.