• One doctor’s experience with the PSA test

    Any reader of this blog knows that we’d always choose data over anecdotes. This is true even when discussing the use of PSA tests to screen for prostate cancer. But every once in a while, a well-told story can put everything in perspective. One such story appeared in yesterday’s Archives of Internal Medicine:

    Fast forward 5 years: cancer free. However, as a result of the surgery, my right arm and right leg are permanently weak, with this deficit appearing immediately after surgery. The reasons for this outcome are unclear. My PSA level remains 0, but my daily 5-mile jog is no longer possible.

    Where am I now on the PSA dilemma in light of the recent US Preventive Services Task Force recommendations? It is clear that prostatectomy results in a very high chance of 20-year prostate cancer–specific survival, but even when the procedure is performed by an expert urologist, it can also result in significant rates of sexual, bladder, and bowel dysfunction and other less common adverse effects, such as my weakness. Active surveillance with longitudinal PSA tests and physical examination is associated with very low rates of bowel, bladder, and sexual dysfunction and has a high probability of correctly identifying when to move from surveillance to treatment. If I could do it all over again, I would not undergo the surgery; instead, I would opt for active surveillance. Even the most informed patient (me in this case) has difficulty making a truly informed decision.

    Screening is not an unequivocal good. It can cause harm. Moreover, it can cost a lot of money. We have to remember that before we just join in lockstep with more and more screening in pursuit of the earliest possible diagnosis. We’ve discussed the studies. But I know some of you need a story.

    Read the whole thing. It’s worth your time.

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    • “If I could do it all over again, I would not undergo the surgery; instead, I would opt for active surveillance.”
      He did NOT say that he would not have had the screening done.
      Was it the screening that caused the harm? Or the decision on how to react to the results?
      (My reactions to PSA screening data/anecdotes are colored by a sample of 2: my husband, alive and well, due to PSA screening in his early 50’s, and a friend, now dead, due to a lack of such screening.)

    • Anne,

      I’m both happy and sad for you regarding your husband and friend. However, you cannot say that Psa screening would have saved your friend and even more so saved your husband.

      Finally, the decision is whether to screen or not. If you never intended to have a therapy regardless of the test, then why screen in the first place.

      • “finally, the decision is whether to screen or not. If you never intended to have a therapy regardless of the test, then why screen in the first place.”

        Active surveillance and definitive treatment (surgery or rx) are both forms of therapy. Active surveillance is just a rigorous screening for those with known low-grade (Gleason 6) prostate cancer to ensure that the cancer is not higher grade or invading out of the prostatic capsule. It involves frequent DRE’s and PSA draws, as well as additional biopsies, and if those tests indicate possible change in condition the typical course is to then provide definitive treatment.

        So what Anne says is exactly right, he does not say that he wouldn’t of had the screening done, he mostly says that he would’ve opted for a more conservative treatment course for his cancer.

        Oddly enough, I think the author really missteps when he brings the question of screening into the discussion of his personal battle with prostate cancer. Active surveillance (his retrospective treatment of choice) was only an option because of the discovery of his cancer (probably by PSA screening…)

        As kind of an aside, as has often been pointed out on this blog, active surveillance is in no way a panacea for the problem of over treatment of low-grade prostate cancer. Active surveillance is still very expensive, very invasive, and very often results in the same outcome (~30% end up getting surgery anyways….)