Prostate cancer screening is important for men who find that they have been identified with advanced PCa disease. If an annual PSA test had not identified a doubling of my PSA (PSADT), in all probability, I would be dead now. The big unanswered question in prostate cancer care and almost every other form of cancer is when did the cancer cells begin to aggressively mutate?
There are opinions that prostate cancer is a form of cancer with a thirty to forty year duration from start to it causing death. For a man whose aggressive prostate cancer begins to mutate while he is an adolescent, there is a good chance that without PSA monitoring that man would suffer an early painful death from the disease.
However, another man’s less aggressive prostate cancer might begin its maturation during his middle-age years, and if he is not having annual PSA monitoring, there is a statistical chance that this man will die with prostate cancer but not from the disease. Something else such as cardiac disease or another form of cancer such as lung cancer may kill him.
With circulating tumor liquid biopsies and better PSMA PET imaging, detection of prostate cancer within a man’s prostate gland at an earlier age might be detected before the prostate cancer has mutated and forced its way through and out of the prostate gland capsule and into the man’s vascular, lymphatic or nervous systems. Once the mutated prostate cancer cells have moved into those pathways, the cancer cells can travel through to the far reaches of the man’s body and become often a systemic incurable disease.
Early detection resulting from early testing and follow-up imaging is always a cost versus benefit analysis. It becomes most important for the patients with the aggressive cancer diseases seeking to make their ailments chronic instead of death sentences. This is something that medical economists and insurance actuaries discus during hospital budget debates, and the men with aggressive prostate cancer are never part of those debates. American medicine is a business first even though almost everyone tries to pretend and argue that it is not.
If I’m not mistaken PSA was originally intended as a means to indicate whether therapeutic intervention was effective for prostate cancer and not as a screening tool to detect prostate cancer. It is an imperfect screen and there should be something better. Perhaps that is in development now.
My spouse has advanced prostate cancer, MCRPC, and it was a rapid increase, while still low, of PSA that indicated there was an issue. That result may result in an increase in life because of therapies. It is what I pray for in this imperfect situation.
“Screening everyone” does not happen now as PCPs do not encourage PSA screening because of SOC guidelines. But, even though my previous PCP always gave me the standard SOC lecture about the unproven value of PSA testing and possible false positives, he would order the PSA test if I insisted. Fortunately, I insisted and the PSADT detected a Gleason 9 Grade Grp 5 aggressive prostate cancer in my prostate gland.
I’m seventy-seven years old, and active intervention five years ago to slow down the progression of the disease might help me die from some other ailment and not from prostate cancer. My father and his five brothers are all dead, and we never had any discussions about prostate cancer. None of the men on my father’s side of my genetic make-up had the disease. My mother’s ale side of the family died prior to the recent genetic testing interest. DNA testing of my family genetics has not revealed any linkage that might have indicated that I would have been at higher risk for prostate cancer.
PSA screening is about all we have to help provide an alert of the presence of prostate cancer. It is an inexpensive blood test . Until there is alternative screening, I think the medical profession should leave the decision for testing up to the patient to decide and not give the patient any opinion based about the SOC averages.
I'm a good friend of J. P. Dwyer (best man at my wedding 28 years ago), with whom I regularly discuss these issues, so I won't repeat his comments. My prostate cancer diagnosis was in 2001 (sudden rise in a low PSA, followed by a free PSA test that suggested cancer was likely), and judged to be aggressive based on reading of the slides by a Dana Farber pathologist. In my case radical prostatectomy was recommended (radiation was out because of other factors) after an endorectal MRI showed no apparent spread to lymph nodes. This was before even laparascopic procedure was available for the surgery, so yes indeed the treatment had a considerable negative effect on quality of life for a while. Recurrence after 4.5 years led to radiation of the prostate bed (80% the likely source, I was told - but I was in the other 20%). Years later, lung nodules could not be determined with certainty to be prostate metastases rather than primary lung cancer, so more surgery - they were prostate mets. (Not too often that a finding of metastatic prostate cancer is greeted with relief!) But PSA continued to rise, and when the doubling time suggested further intervention, docetaxel (chemo) plus leuprolide (hormone therapy) was initiated - definitely negative for quality of life, for a few months. After seven years, I've been moved to darolutamide, an androgen receptor inhibitor - within six months, PSA undetectable and leuprolide discontinued. Leuprolide suppresses testosterone; darolutamide just makes it unavailable to the cancer cells, and so far seems more effective. Was it all worth it? No way to tell - I'm still here, age 80, after 23 years of treatments, still active in research in my chosen field. -- An anecdotal tale: at the time I was diagnosed, there were seven other men at the college I worked at who were diagnosed with prostate cancer within a two-year period. We knew one another (and got to know each other better after diagnosis!), and kept in touch. One of us opted for what was then called "watchful waiting"; the others all chose some form of treatment (four chose surgery, as I did; two older men chose radiation). The one who chose watchful waiting apparently did not have very good monitoring, as he died in less than two years. One who chose surgery died after 19 years at age 83. Most of us are still going (I've lost touch with a couple, but their obituaries haven't appeared on the college web site), one having just turned 91 and published yet another book this year. Anecdotal, of course - David Keith's question might have something interesting to say about us. -- I can only second the desire for a better way to screen for prostate cancer, but until then, openness about the uncertainty is called for, so each man can make his own decision how to proceed (though inevitably one's physician's opinion will be a factor).
I've gotten burned with not screening high risk younger men--Black men in their 50's. I did hear Otis Brawley speak about 10 years ago about the lack of benefit-when he was involved with ACS. And having a family member with a very high family risk--likely BRCA related--it reminds me to individualize risk as best possible.
I’ve met Otis Bradley a couple of times and he is as interesting and intelligent in person as he is in writing and speaking.
I’ll just add two things. First, as you said, high risk vs low risk. I think the “screen everyone” approach really distracts from a focus on high risk, where I would imagine it might actually help. Second, as hard as it is, don’t beat yourself up. It’s often the case (see the 3rd curve), that you could have diagnosed a cancer early but gotten the same outcome. It’s an unpleasant reality of screening. It leads to “lead time bias,” not to mention guilt. It’s not an easy job and I know you care a lot!!
Prostate cancer screening is important for men who find that they have been identified with advanced PCa disease. If an annual PSA test had not identified a doubling of my PSA (PSADT), in all probability, I would be dead now. The big unanswered question in prostate cancer care and almost every other form of cancer is when did the cancer cells begin to aggressively mutate?
There are opinions that prostate cancer is a form of cancer with a thirty to forty year duration from start to it causing death. For a man whose aggressive prostate cancer begins to mutate while he is an adolescent, there is a good chance that without PSA monitoring that man would suffer an early painful death from the disease.
However, another man’s less aggressive prostate cancer might begin its maturation during his middle-age years, and if he is not having annual PSA monitoring, there is a statistical chance that this man will die with prostate cancer but not from the disease. Something else such as cardiac disease or another form of cancer such as lung cancer may kill him.
With circulating tumor liquid biopsies and better PSMA PET imaging, detection of prostate cancer within a man’s prostate gland at an earlier age might be detected before the prostate cancer has mutated and forced its way through and out of the prostate gland capsule and into the man’s vascular, lymphatic or nervous systems. Once the mutated prostate cancer cells have moved into those pathways, the cancer cells can travel through to the far reaches of the man’s body and become often a systemic incurable disease.
Early detection resulting from early testing and follow-up imaging is always a cost versus benefit analysis. It becomes most important for the patients with the aggressive cancer diseases seeking to make their ailments chronic instead of death sentences. This is something that medical economists and insurance actuaries discus during hospital budget debates, and the men with aggressive prostate cancer are never part of those debates. American medicine is a business first even though almost everyone tries to pretend and argue that it is not.
I think the first key to doing this right is to tease out risk, as you say.
I bet if you focus on people with first or second degree relatives, you get closer to something useful.
But “screen everyone” just doesn’t seem to work.
If I’m not mistaken PSA was originally intended as a means to indicate whether therapeutic intervention was effective for prostate cancer and not as a screening tool to detect prostate cancer. It is an imperfect screen and there should be something better. Perhaps that is in development now.
My spouse has advanced prostate cancer, MCRPC, and it was a rapid increase, while still low, of PSA that indicated there was an issue. That result may result in an increase in life because of therapies. It is what I pray for in this imperfect situation.
“Screening everyone” does not happen now as PCPs do not encourage PSA screening because of SOC guidelines. But, even though my previous PCP always gave me the standard SOC lecture about the unproven value of PSA testing and possible false positives, he would order the PSA test if I insisted. Fortunately, I insisted and the PSADT detected a Gleason 9 Grade Grp 5 aggressive prostate cancer in my prostate gland.
I’m seventy-seven years old, and active intervention five years ago to slow down the progression of the disease might help me die from some other ailment and not from prostate cancer. My father and his five brothers are all dead, and we never had any discussions about prostate cancer. None of the men on my father’s side of my genetic make-up had the disease. My mother’s ale side of the family died prior to the recent genetic testing interest. DNA testing of my family genetics has not revealed any linkage that might have indicated that I would have been at higher risk for prostate cancer.
PSA screening is about all we have to help provide an alert of the presence of prostate cancer. It is an inexpensive blood test . Until there is alternative screening, I think the medical profession should leave the decision for testing up to the patient to decide and not give the patient any opinion based about the SOC averages.
I literally cried tears of joy when I first saw those Kaplan-Meir curves from the COVID vaccine trials.
Same!!!!! I often say that it was one of the best days of my life that I had nothing to do with
I did too - I was in the Pfizer Covid vaccine trial so it was extra special to see it worked! (I was placebo group).
Do the results get any more interesting if broken down by age at diagnosis, stage at diagnosis, and treatment chosen?
I'm a good friend of J. P. Dwyer (best man at my wedding 28 years ago), with whom I regularly discuss these issues, so I won't repeat his comments. My prostate cancer diagnosis was in 2001 (sudden rise in a low PSA, followed by a free PSA test that suggested cancer was likely), and judged to be aggressive based on reading of the slides by a Dana Farber pathologist. In my case radical prostatectomy was recommended (radiation was out because of other factors) after an endorectal MRI showed no apparent spread to lymph nodes. This was before even laparascopic procedure was available for the surgery, so yes indeed the treatment had a considerable negative effect on quality of life for a while. Recurrence after 4.5 years led to radiation of the prostate bed (80% the likely source, I was told - but I was in the other 20%). Years later, lung nodules could not be determined with certainty to be prostate metastases rather than primary lung cancer, so more surgery - they were prostate mets. (Not too often that a finding of metastatic prostate cancer is greeted with relief!) But PSA continued to rise, and when the doubling time suggested further intervention, docetaxel (chemo) plus leuprolide (hormone therapy) was initiated - definitely negative for quality of life, for a few months. After seven years, I've been moved to darolutamide, an androgen receptor inhibitor - within six months, PSA undetectable and leuprolide discontinued. Leuprolide suppresses testosterone; darolutamide just makes it unavailable to the cancer cells, and so far seems more effective. Was it all worth it? No way to tell - I'm still here, age 80, after 23 years of treatments, still active in research in my chosen field. -- An anecdotal tale: at the time I was diagnosed, there were seven other men at the college I worked at who were diagnosed with prostate cancer within a two-year period. We knew one another (and got to know each other better after diagnosis!), and kept in touch. One of us opted for what was then called "watchful waiting"; the others all chose some form of treatment (four chose surgery, as I did; two older men chose radiation). The one who chose watchful waiting apparently did not have very good monitoring, as he died in less than two years. One who chose surgery died after 19 years at age 83. Most of us are still going (I've lost touch with a couple, but their obituaries haven't appeared on the college web site), one having just turned 91 and published yet another book this year. Anecdotal, of course - David Keith's question might have something interesting to say about us. -- I can only second the desire for a better way to screen for prostate cancer, but until then, openness about the uncertainty is called for, so each man can make his own decision how to proceed (though inevitably one's physician's opinion will be a factor).
I've gotten burned with not screening high risk younger men--Black men in their 50's. I did hear Otis Brawley speak about 10 years ago about the lack of benefit-when he was involved with ACS. And having a family member with a very high family risk--likely BRCA related--it reminds me to individualize risk as best possible.
I’ve met Otis Bradley a couple of times and he is as interesting and intelligent in person as he is in writing and speaking.
I’ll just add two things. First, as you said, high risk vs low risk. I think the “screen everyone” approach really distracts from a focus on high risk, where I would imagine it might actually help. Second, as hard as it is, don’t beat yourself up. It’s often the case (see the 3rd curve), that you could have diagnosed a cancer early but gotten the same outcome. It’s an unpleasant reality of screening. It leads to “lead time bias,” not to mention guilt. It’s not an easy job and I know you care a lot!!