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A physician's interesting outlook on changing PSA recommendations

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Prostate Cancer
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BillyBob@388
Veteran Member
Joined : Mar 2014
Posts : 4855
Posted 9/1/2017 8:00 PM (GMT -8)
jamanetwork.com/journals/jamainternalmedicine/article-abstract/2645148?widget=personalizedcontent&previousarticle=2653029

Somebody said...
No Wonder No One Trusts Us
I am trying to envision how my conversation might go with a patient who is male and older than 50 years, now that the latest draft of the US Preventive Services Task Force recommendations fro prostate cancer screening has been released........................

I guess this ongoing debate causes confusion to providers as much as patients.

Post Edited (BillyBob@388) : 9/1/2017 10:11:42 PM (GMT-6)

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lifeguyd
Veteran Member
Joined : Jul 2006
Posts : 691
Posted 9/2/2017 5:19 PM (GMT -8)
I think we all understand that the practice of medicine is not an exact science. Since my diagnosis in 2006 prostate cancer treatment and screening have gone through a roller coaster ride of changes. Knowing what I know today, I would have had different treatment, but might not have been treated all if my physician was influenced by the "don't psa test" movement that now seems to be ending.

Medicine is like that. I have been taking statin drugs for 25 years that probably extended my life but are now found to cause other problems. The same can be said for the blood pressure drugs and proton pump inhibitors that were a part of my life for decades. I now suffer from problems from kidney disease to peripheral neuropathy that apparently were at least enhanced by those doctor prescribed medications.
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halbert
Veteran Member
Joined : Dec 2014
Posts : 5818
Posted 9/2/2017 5:30 PM (GMT -8)
Part of the issue is how the press deals with it--the banner headlines, the statements of absolute certainty, and all the rest create problems. I get where the doctor is coming from. He does have a problem, how to explain things.
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mattam
Veteran Member
Joined : Aug 2015
Posts : 3991
Posted 9/2/2017 6:51 PM (GMT -8)
The first line of my signature summarizes my view. I would do well to limit my comments to that.
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RobLee
Veteran Member
Joined : Apr 2017
Posts : 1488
Posted 9/3/2017 6:18 AM (GMT -8)

mattamx said...
The first line of my signature summarizes my view.
"The tragic recommendations of the USPSTF led me to where I am."

I'm right behind you Bro, by about one year, with steadily climbing PSA yet neg DRE's.
It's odd that a DRE can get you treatment, but a blood test will not. Who dreams up this stuff?
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mattam
Veteran Member
Joined : Aug 2015
Posts : 3991
Posted 9/3/2017 7:03 AM (GMT -8)
Sadly, over time, I have to believe that more and more guys with advanced PCa will be wandering in here looking for support.
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halbert
Veteran Member
Joined : Dec 2014
Posts : 5818
Posted 9/3/2017 7:19 AM (GMT -8)
Matt, Rob, when the recommendations were published (right after I came in here), there were heated debates (and multiple locked threads) where the defenders who were on the overtreatment bandwagon were going at it with those who were predicting your situations.

And, I think, the pull back on the new recommendations are based on that argument. Unfortunately, the damage is done.
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mattam
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Joined : Aug 2015
Posts : 3991
Posted 9/3/2017 7:49 AM (GMT -8)
I hear you Halbert. I have witnessed some of those contentious "discussions." I don't want to incite a riot or a locked thread. As I said, I mostly limit my thoughts on the matter to what is in my signature. The Task Force recommendations are what they are. My energy and interest is directed more to supporting the guys who be negatively affected by the recommendations.
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BillyBob@388
Veteran Member
Joined : Mar 2014
Posts : 4855
Posted 9/3/2017 11:02 AM (GMT -8)

lifeguyd said...
I think we all understand that the practice of medicine is not an exact science. Since my diagnosis in 2006 prostate cancer treatment and screening have gone through a roller coaster ride of changes. Knowing what I know today, I would have had different treatment, but might not have been treated all if my physician was influenced by the "don't psa test" movement that now seems to be ending.

Medicine is like that. I have been taking statin drugs for 25 years that probably extended my life but are now found to cause other problems. The same can be said for the blood pressure drugs and proton pump inhibitors that were a part of my life for decades. I now suffer from problems from kidney disease to peripheral neuropathy that apparently were at least enhanced by those doctor prescribed medications.

That right there supplies some serious food for thought. There is a tendency in medicine(or should I say a SE?) to (maybe/hopefully) fix one thing but break another while doing so. I teach a class populated by men on average 20 years my senior, into their 80s and 90s, WW2 vets. Most likely, medicine(and/or surgery or RT) has kept many of them alive and active a good bit longer than they would have been without it. Still, most are on a number of prescription meds, and I hear from them about the SEs associated with them. One almost had a ruptured Achilles tendon related to the antibiotics they put him on and quickly stopped, another had a strange and severe reaction to proton pump inhibitors, but most common is guys getting treated for their high BP and then they start falling down. More than one has quit their meds because of falling. Considering the severity of the consequences of these seniors falling, it might be debatable as to which is more dangerous: the high BP or the falling. But since they can no longer function if they are falling a lot, many decide to take their chances on the high BP. One guy has told me that he can just be standing there talking to someone when he just- before he knows it is happening- falls over backwards! This will happen every time he tries to start a certain BP pill that his docs want him to take. Sigh.

I have no doubt that I would have been on BP pills for 20 years now, if I had gone to the doctor when my BP and weight were heading steadily higher. I was only in my late 40s(68 now, no prescription meds), and my BP had started staying above 140/90 or higher, plus my triglycerides had been flagged at a bit over 200, and HDL quite low. But I put off seeing anyone for a pill while I tried several versions of low carb/higher fat eating. Against medical advice I might add. Within 6 months my BP was lower than when I was 20, at around 105/60, and my triglycerides(TGL) had dropped into the 40s and HDL came up nicely. (also, lots of weight lost).

Now I could have simply treated that high BP with a pill that any doc would have been happy to provide. But I prefer the way it worked out for me, rather than taking BP meds(and probably a med for my TGL and cholesterol). And as in your example, maybe finding out about some of the surprise SEs way down the road. Also, though I did have docs advise me to lose weight, which I had been unable to do, I never had a single doc advise me to eat lower carb/higher fat, which turned out to work pretty darn well for me.

Post Edited (BillyBob@388) : 9/3/2017 2:34:18 PM (GMT-6)

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ASAdvocate
Veteran Member
Joined : Feb 2015
Posts : 1052
Posted 9/3/2017 11:21 AM (GMT -8)

halbert said...
Matt, Rob, when the recommendations were published (right after I came in here), there were heated debates (and multiple locked threads) where the defenders who were on the overtreatment bandwagon were going at it with those who were predicting your situations.

And, I think, the pull back on the new recommendations are based on that argument. Unfortunately, the damage is done.

IMHO, The psa test was never the issue for overtreatment, it's how that result was discussed by the doctor and acted on by the patient. The logic was that an elevated psa led to unnecessary biopsies and prostatectomies.

A high psa should have been followed up with a second test, and also a free psa result. That alone could have eliminated many biopsies. An MRI would also have been valuable.

Beyond a positive biopsy, there was a concern that men with low risk status were being railroaded into treatment, and not advised of options like active surveillance. That, in my opinion, was where the problem was, not with the psa test or the biopsy.

I have never heard a man with low risk cancer who is on AS say he regretted knowing the diagnosis. I have heard men who were diagnosed years ago complain that their doctors rushed them into surgery without discussing their alternatives. I think that those complaints factored into the task force's decision.

The controversy won't die down until there is a better initial diagnostic test. We'll get there, someday.
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halbert
Veteran Member
Joined : Dec 2014
Posts : 5818
Posted 9/4/2017 4:38 AM (GMT -8)
I do like the idea of calling G6 "pre-cancer", which is used to define various other things we can get, from colon polyps to certain skin lesions. This would have the practical effect of putting everyone with a G6 biopsy onto AS until something changes.
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JNF
Veteran Member
Joined : Dec 2010
Posts : 5726
Posted 9/4/2017 4:43 AM (GMT -8)
Hal, while I tend to agree, that would have put many surgeons including the great Patrick Walsh out of business.

As wonderful as the nerve sparing procedure is it undoubtedly has committed thousands of men to unessecary over treatment.
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RobLee
Veteran Member
Joined : Apr 2017
Posts : 1488
Posted 9/4/2017 7:19 AM (GMT -8)

JNF said...
As wonderful as the nerve sparing procedure is it undoubtedly has committed thousands of men to unessecary over treatment.

Surgeon asked me about nerve sparing, I just said do what you can, but that's not as important as getting all the cancer. As a result he used a broad cut, the result being neg margins and neg nodes. The cost, incontinence and most likely ED (though much of that is likely due to the Lupron).

As far as "getting all the cancer", irradiating the SV bed will hopefully be the end.
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Larry E
Regular Member
Joined : May 2016
Posts : 162
Posted 9/4/2017 9:20 AM (GMT -8)
I was advised by my old primary care doctor, who always told me PSA test not required DRE negative and I never had the test till he retired in 2015.
My new primary care Dr said I needed the PSA test, so explained it was not required and he said ok but I recommend you get it, so I did. First PSA test came back 181 after a round of antibiotics and another office visit with new primary care Dr I was referred to Urologist.
When I saw Urologist DRE negative but my PSA came back 203 so a biopsy was scheduled and the rest is history on my signature.

There is “no reason not to get PSA test” ask me or any of thousands of men who pay the price of not being screened. High grade High volume, metastatic.
Larry
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BillyBob@388
Veteran Member
Joined : Mar 2014
Posts : 4855
Posted 9/4/2017 9:39 AM (GMT -8)

Larry E said...
I was advised by my old primary care doctor, who always told me PSA test not required DRE negative and I never had the test till he retired in 2015.
My new primary care Dr said I needed the PSA test, so explained it was not required and he said ok but I recommend you get it, so I did. First PSA test came back 181 after a round of antibiotics and another office visit with new primary care Dr I was referred to Urologist.
When I saw Urologist DRE negative but my PSA came back 203 so a biopsy was scheduled and the rest is history on my signature.

There is “no reason not to get PSA test” ask me or any of thousands of men who pay the price of not being screened. High grade High volume, metastatic.
Larry

I don't see how a rational argument can be made against just having the test, considering the results in cases like yours. Now a big debate can be had about the results of over treatment, and how the average patient going to his local docs can be protected from that, what with the average patient being pretty ignorant of these things, and totally trusting their doctors.
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Larry E
Regular Member
Joined : May 2016
Posts : 162
Posted 9/4/2017 10:03 AM (GMT -8)
Yes I agree BillyBob, the PSA test in itself is not bad.

It is required to be vigilant for the 2% of us that have no physical symptoms and need the PSA to catch PC.
Larry
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RobLee
Veteran Member
Joined : Apr 2017
Posts : 1488
Posted 9/4/2017 10:10 AM (GMT -8)
I've said it here before, I trusted my urologist when my GP sent me to him with a rising PSA. Uro did DRE, said it was unremarkable. PSA kept rising, so he did a biopsy. It was negative. He never even mentioned anything about cancer.

My biggest complaint is doctors do not INFORM their patients. I guess an informed patient is a potential lawsuit.
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