There IS No Normal PSA...

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Fairwind
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Date Joined Jul 2010
Total Posts : 2368
   Posted 1/15/2011 12:59 PM (GMT -7)   
Reading Dr. Chodak's new book, "Winning the Battle Against Prostate Cancer, I came across this tidbit..A well-done study proved there was no "normal" PSA reading and the PSA number by itself was almost useless as an indicator for predicting prostate cancer..In this study, a large group of men with NORMAL DRE's were given biopsies..The results were startling. In men with PSA readings between 0 and 1.0, 16% had cancer..
between 1.1 and 2.0, 28% had cancer..

The new rules for getting a biopsy are:

1) An abnormal DRE
2) An initial PSA reading of 2.5 or greater without any other
reason for it to be elevated.
3) A rise in PSA level of over .75 ng/ml per year based on three PSA tests done over a period of at least 18 months.
4) A doubling of PSA score in three years or less..

So now PSA velocity becomes more important than the actual number...

A biopsy is recommended if ANY of the four conditions above exist...
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
" 61: 5.2
" 64: 7.5, DRE "Abnormal"
" 65: 8.5, " normal", biopsy, 12 core, negative...
" 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
" 67 4.5 DRE "normal"
" 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT NOW

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3142
   Posted 1/15/2011 2:04 PM (GMT -7)   
I still believe Dr. Strums criterias for psa testings and overall assessments on PCa...trumps our Surgeon friend. Dr. C's replies on PPML about SRT to that mans questions, were applauling and filled will arogance. I will leave it there before I say more. Decide for yourselves whom the experts are, forget the self proclaimed.
Dx-2002 total urinary blockage, bPsa 46.6 12/12 biopsies all loaded 75-95% vol.; Gleasons scores 7,8,9's (2-sets), gland size 35, ct and bone scans look clear- ADT3 5 months prior to radiations neutron/photon 2-machines, cont'd. ADT3, quit after 2 yrs. switched to DES 1-mg, off 1+ yr., controlled well, resumed, used intermittently, resumed useage

Tony Crispino
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Date Joined Dec 2006
Total Posts : 7715
   Posted 1/15/2011 3:19 PM (GMT -7)   
Zufus,
Perhaps a better approach would be to state what is different about Strums approach. I know Strum to be retired and I also know information about prostate cancer to be a moving target. Strums book was written nearly ten years ago with the latest revision in 2005. Much has changed about the subject that Fairwind has posted in the last 6 years.

I know you have expressed very aggressive opinions towards any specialist in the urological community...but a personal attack is less valuable than a statement of specific facts about why you disagree with anyone.

Peace.

Tony

ralfinaz
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Date Joined Jan 2011
Total Posts : 713
   Posted 1/15/2011 5:04 PM (GMT -7)   
Hi Fairwind,
Can you give us the reference about the study mentioned? Thanks.

RalphV
Surviving prostate cancer since 1992. RP; Orchiectomy (OUCH!)
GS (4 + 2); bilateral seminal vesicle invasion; tumor attached to rectal wall. Last PSA September, 2010: <0.1 ng/ml
Laughter is the best medicine!

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 1/15/2011 5:17 PM (GMT -7)   
The "new" book has "old" information...

There is a continuium of risk at all PSA values, with higher PSA values associated with a higher risk of prostate cancer. The American Urological Association (AUA) does not recommend a single threshold value which should prompt a prostate biopsy.

The AUA writes:
"The decision to proceed to prostate biopsy should be based primarily on PSA and DRE results but should take into account multiple factors, including free and total PSA, patient age, PSA velocity, PSA density, family history, ethnicity, prior biopsy history and comorbidities."

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 24343
   Posted 1/15/2011 5:34 PM (GMT -7)   
Fairwind, my own personal PC journey has been all about PSA velocity from day one, and so far, the velocity factor is trumping, at least for me, all attempts to arrest the cancer. I am becoming a poster child for those supporting the velocity issue.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Worried Guy
Veteran Member


Date Joined Jul 2009
Total Posts : 3278
   Posted 1/15/2011 6:36 PM (GMT -7)   
"the PSA number by itself was almost useless as an indicator for predicting prostate cancer."
Not if it is above 10! But you don't know until you get the PSA number.

I also note that 3 out of the 4 indicators depend upon getting the PSA test.

I had normal DREs at all my physicals but did not have a my first PSA until I was 56 when it was found to be 17+. A couple of weeks later after antibiotics it was 22+ The biopsy confirmed 7 positive out of 12 with up to 70%

It was the PSA test demanded by my insurance company that first indicated I had a problem. Thank you MetLife (even though they declined to insure me.)

Jeff

John T
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Date Joined Nov 2008
Total Posts : 3760
   Posted 1/15/2011 7:34 PM (GMT -7)   
A single psa number should never be taken alone, as psa can come from other issues besides prostate cancer. There are also agressive varients that don't have any psa. A consistant rise of psa over time is a major indicator of PC, as is psa doubling time. Dr Strum said that in his 40 years of practicing he has never seen a psa doubling time less than 12 years not be eventually DXed as PC.
1.5 million men per year get biopsies in the US and about 50% of all men will have a biopsy sometime in their lifetime. about 50% of all biopsies are done for elevated psa due to BPH. This is very easy for a doctor to determine because the size of a prostate is directly related to the psa in the blood stream. From Dr Epstien's research we know that we should be concerned with a psa density >1.5 (prostate size in cc divided by 10) X 1.5). For a 40 cc prostate (normal for a 60 year old) a psa of over 6 would be a red flag. Since the normal prostate for a 50 year old man is about 30cc and would have a normal psa range of 2 to 4.5, if we used Dr Chodak's threshold of 2.5 then just about every man in the US would get a biopsy.
Reducing the biopsy threshold will only result in more men with BPH getting biopsies and many more cases of indolant cancer being discovered. Doctors have to be smarter and use mutiple points of information such as free psa, psa density, psa velocity and psa doubling time along with PCA3 and color doppler instead of simply recommending a biopsy when psa hits a magic threshold.
I don't know about anyone else, but I think that 1.5 million biopsies a year and half of them being done for psa easily explained by BPH is something that shouldn't be tolorated. Doctors are way too quick to pull the biopsy trigger, just as they are way too quick to request CT and bone scans for low rsk PC patients. It could be because of profit motive or the fear of litigation; I personally believe it is because of lack of knowledge.

JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 7715
   Posted 1/15/2011 7:47 PM (GMT -7)   
John,
It's important to note that Chodak's comments are "an initial PSA of 2.5 without any other reason for it to be elevated". To me this means that UTI, prostatitis, or other eliments must be eliminated first.

As a person who has met Chodak I know him to be extremely conservative about treating prostate cancer and he is not saying "2.5 well then act...". he is setting a few things to look at that are indeed found in the Strum book. The funny part is that I was once on a stage with him and I disagreed about AS. He was very nice about it and stuck to his guns that there needs to be a lot more of it.

Once again, he is known for promoting active surveillance and PSA monitoring long before most top of the line prostate cancer oncologists.

To all:
Please read the book. It might surprise some folks and make some others mad. But like many other book's criticism from anyone who hasn't or refuses to read it is questionable....

(Revised...I added a comment)

Tony

Post Edited (TC-LasVegas) : 1/15/2011 7:44:10 PM (GMT-7)


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2627
   Posted 1/15/2011 9:06 PM (GMT -7)   
Maybe I've had PC too long. I seem to be getting more cynical of the new experts in the field, and in fact get tired of the constant references to the PC prophets who have written books in the past.

I am following a common sense approach to much of this. Perhaps a PSA of 4 is not the correct number for every one, but there is a number that is abnormal. As Jeff pointed out, certainly a 10 is abnormal. If we are unfortunate enough to have a high gleason PC that does not produce a lot of PSA, probably in a lot of trouble anyway.

PSA testing, coupled with DRE's, is still the most effective way we have of detecting PC that we have, coupled with biopsy, today. I fail to see the argument that there is nobnormal PSA. For a very high percentage of men, there appears to be high correlation between elevated PSA and a positive DRE.

I really have not found this to be a difficult concepts to grasp, have decided not to write a book. This simple concept has certainly lengthened my life, if not saved it.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3760
   Posted 1/15/2011 9:17 PM (GMT -7)   
Tony,
I have nothing against Chodak, and I understand what he meant about the 2.5 psa and eliminating other reasons for elevated psa. My problem is that doctors will take this 2.5 and treat it just like the old standard of 4.
Just like 12 years ago when I was told "your psa is 4.4 so you need a biopsy." In 10 years I never had one doctor calculate a psa density or psa doubling time until I saw Dr Scholz and Dr Bahn and that was the 1st thing they both did. Once a psa number gets thrown out like 2.5 or 4 it just becomes automatic for a lot of doctors to recommend a biopsy without taking the additional steps to see if it is really warrented. If we now have 1.5 million biopsies a year, and 750,000 are unnesssary, how many more will result in the change of a standard to 2.5?
I haven't read Chodak yet and plan to do so. Strum was writing about how to differentiate BPH from PC 10 years ago and very few doctors got the message.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 24343
   Posted 1/15/2011 9:20 PM (GMT -7)   
Goodlife, I appreciate you not wanting to write the next "Super Prostate Cancer" book. Like all diseases and cancers in particular, its easy for someone with some credentials to get into the let's make some money off of what I know thinking.

Though this isn't a popular opinion, the "Invasion of the Prostate Snatchers" book crossed the line with me. What the doctor side of the book said is somewhat useful, though hardly an improvement over Walsh's great standard on the subject, but when he hooked up with Mr. New Age, it lost it with me. Couldn't take the whole presentation seriously at that point.

We don't need new books. We need better testing, back to knowing if a diagnosed PC is aggressive or docile by nature, that, along with conventional PSA and DRE's, would give a better basis for the rest of us to make our tough decisions with.

Despite the "wisdom" of the experts, and the wan-a-bee experts, despite even the best of our doctors, when push comes to shove, everyone backs away at decision time, and we have to make the decision. To treat, or not treat, how to treat, and hope to God that we are half-way right.

David
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 7715
   Posted 1/15/2011 9:52 PM (GMT -7)   
John T,
Yea I know what you are saying about your history 12 years ago but I don't think that is thesame circumstances as much in 2011. We need to see doctors learn the lessons from 12 years ago and combine them today's growing thinking. On the other hand it would not be unreasonable to test for prostate cancer today when your PSA was at 4.4 at such an early age, as it was likely present, to when your PSA hit 40 twelve years later without the need need of those other tests. When I was diagnosed ahead of you, it made little sense for me or my doctors to wait for velocity results when antibiotics could not bring my PSA down from 19.8. Even if it was not prostate cancer, a biopsy was reasonable. And thank goodness no one questioned that decision.

Good luck and good reading. If you need to ask Chodak any questions about what you see I do have his contact info...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3760
   Posted 1/16/2011 12:11 PM (GMT -7)   
Tony,
I think you missed my point, which was that most doctors are unable to distinguish BPH from PC and use the tools and knowledge available to avoid unnecessary biopsies. This is not a 12 year old problem and exists today. In both of our situations biopsies were warrented as PC was clearly indicated and could not be explained by BPH or prostatitis. My first biopsy was in 1999. By 2003 when psa had reached 16 it was pretty obvious that my psa could not be explained by BPH or anything else, yet I was continually DXed with BPH until late 2009. (the reverse problem that most men have). The multiple data points of PSA over a long time period clearly indicated PC.
In most cases psa's in the range of 2 to 8 are due to BPH and can be easily determined by simple math. All I'm saying is that hundreds of thousand of men each year are given biopsies that could have been avoided by using some simple tools that have been available for years.
JT

Paul1959
Veteran Member


Date Joined Nov 2007
Total Posts : 597
   Posted 1/16/2011 2:38 PM (GMT -7)   
Frankly, I would not trust anyone, or any study, that tries to make a blanket statement about anything having to do with PCa. Period. Only a fool would set rules for a disease that follows no rules! LOL
Paul
Founder, Erectile Dysfunction Foundation and creator of www.franktalk.org The site for erectile dysfunction.

46 at Diagnosis.
Davinci at 47.
Doing fine.
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