Saturday, July 25, 2009

Prostate Cancer Screening: Stop The PSA Train!


About 10 years ago, my dad was to see his general internist. I have always refrained from giving medical advice to my family, for all of the reasons why doctors should not treat or advise their relatives. But, on this occasion, I did give Dad some unsolicited advice, particularly as I knew that his physician fired the diagnostic testing trigger readily.

“Dad, please make sure that he doesn’t check the PSA (prostate specific antigen) test.” Dad indicated that he would convey my concern to his doctor, who ran the test on him anyway. Apparently, he includes the PSA test as a matter of routine on all men over a certain age.

Twenty-five years ago as a curious, but skeptical medical student, I learned about prostate cancer. I learned that every man will develop it if he lives long enough. I learned that most cases of prostate cancer remain silent and never interfere with the individual’s life. I learned that the treatment for these cancers involves either major surgery or radiation, both of which can markedly diminish the quality of mens’ lives by causing urinary leakage, chronic diarrhea and rectal bleeding and sexual dysfunction. These lessons are just as true in 2009, yet they are largely ignored by a juggernaut of physicians, medical societies and hospitals, who have conflicts of interest on this issue. These PSA proponents are not corrupt, they are just blinded by their biases.

Men are strongly urged to pursue early diagnosis of prostate cancer under the false premise that this will lengthen and improve their lives. The PSA test, which is championed by so many physicians, has achieved exactly the opposite results. It has been an entry point for men who are pushed down a slippery slope into a medical minefield. Like many medical cascades, it is very difficult to change the course of this journey once it has begun. Once a PSA value is abnormal, it becomes almost impossible for patients and physicians to resist the pressure for prostate ultrasounds and biopies. The time to discuss prostate screening with patients in detail is before the blood test is done, not afterwards when the result is elevated or borderline.

The treatments for prostate cancer harm thousands of men across the country, most of whom would never have been disturbed by their silent cancers. This is a true medical travesty. Urologists and others dispute my views and earnestly believe that they are saving lives. I believe they are sincere and properly motivated. Yet, while they may be saving a few men, this must be balanced against the direct harm, financial cost and anxiety of patients and their families that are ultimate PSA casualties. Personally, I am mystified why the PSA screening test wasn’t banned from medical practice years ago.

Here’s what a study published in the prestigious New England Journal of Medicine concluded earlier this year. In order to save a single life from prostate cancer, about 1400 men would have to be screened. How do those odds sound? Read on. About 50 of these men would endure prostate cancer treatments, as I described above, that would not benefit them, either because the disease would have remained silent or was already too advanced to be helped medically. Still interested in getting a PSA test?

It’s a tragedy when a patient suffers chronic complications from a treatment that was not necessary. If comparative effectiveness research, which aims to scientifically determine which medical treatments are supported by evidence, ever gets airborne, I hope that PSA becomes a very high priority item.

PSA testing is a complex issue and calls for discussion between patients and physicians before any testing is undertaken. It should not be casually added to a panel of blood tests, deferring the conversation until afterwards, when it may be too late to derail the prostate locomotive.

The PSA is more accurately a Physician Scam Activity, than it is a lifesaving screening test, even though the physicians’ intentions may be pure.

When your doctor advises any test, particularly the PSA, make sure that you understand where the result could lead you. Regrettably, many men like my dad have the test sent off without their knowledge. Fortunately, his PSA result was normal. Otherwise, the prostate train may have taken him into a tunnel with no way out.

73 comments:

Anonymous said...

You raise some key points and I have some key agreements and some key disagreements. Definitely the “conflicts of interest” (or should I say income) on the part of physicians is a major problem impeding progress, as is the lack of “comparative effectiveness” measures. However, I think the first place we need to look is at physicians and medical schools. The NY Times of July 25 “Hospital Savings: Salaries for Doctors Not Fees” Gardiner Harris he argues that a first step in health care reform should be elimination of payment for procedures in hospitals replaced by salary as in the prestigious Cleveland Clinic. And what about MD’s salaries relative to the value to society and the effectiveness of their practices. It’s almost impossible to get objective data on MD’s in this regard – let’s have objective evaluation and transparency for these folks in whose hands we place our lives and saving. Harris points out that, for example, gastroenterologists, average $475,000 per year and the top 10% make $715,716. Wow talk about overpayment, that’s more than most successful Division I football coaches make, and the coaches bring joy to many more folks, and have their jobs on the line each season. Lets have win loss statistics for our physicians and pay them accordingly. And talking about college education, what’s the deal with getting into med school? Could it be that the med schools are keeping down admissions to keep up income, and focusing admission on too many money hungry undergrads who learn how to “play the game” to get into med school rather than focus on humanity, ethics, and substance. Perhaps that’s why so many Med school classes seem to focus on memory and regurgitation and effectively punish intellectual approaches. I know many of the students who studied biomedical engineering in my program were shocked and the lack of intellectual rigor, and even basic facts, in so many of their med school classes. And how about MCATs --- has anyone ever did a comparative effectiveness. And isn’t it true that once a student is accepted in Med school it’s almost impossible to flunk out --- talk about lack of quality control.
Getting back to screening I think your attitude is that of just another patronizing MD who want’s to play God. Screening, be it PSA screening, mammography, colonoscopy is under attack. The idea seems to be wait till you are on or over the edge of invasive cancer, and then come to us. We can then apply all sorts of life extending treatments (not discussed in the anti screening movement) to slow the attack of cancer, and your life will be as long --- but fighting cancer the whole time. The prestigious PSA studies are widely known to be corrupted and incomplete, as well as out of date. I would imagine they were published for political reasons and in any case the approach to Prostate cancer has gone well beyond the unthinking approach used in the surveys, beginning with PSA screening, multiple measures of PSA activity. possible biopsy, and active surveillance based on predictive criteria. But I do admit that we lay folks need to know more about what we are getting into before being screened be it PSA tests, mammography, etc. Finding out one has a potential problem does not lend well to making appropriate decisions. It’s just as bad in my opinion to be scared into treating a cancer that doesn’t need treatment, as to scared out of screening by a patronizing Dr. who says we ought no know the state of our health and the potential for invasive cancer as it applies to us as individuals but rather need to be treated as one of an instiguishable subject of a massive study. Ultimately what the anti screening movement is saying is my life as individual doesn’t matter to them since on average treatment isn’t needed.

Anonymous said...

Sorry I didn't edit my previous post but you get the jist of it.
Lee Smith (anonymous)

Diane Bisgeier said...

hi Dr. Kirsch-
Interesting post indeed; clearly the slippery slope of overtreatment is something we need to be mindful of. How do you suggest men screen for prostate cancer if you advocate avoiding the PSA test altogether?

Anonymous said...

The anti screening philosophy for prostate cancer, and also perhaps for breast cancer, e.g. DCIS, seems to be that since screening can lead to false alarms, since folks can be frightened into treatment because of fear of cancer, since this can lead to overtreatment of cancer that would never become invasive, then let's just wait for more serious symptoms and spread of cancer -- to be sure we are not overtreating. Indeed some would claim invasive cancer can disappear on it's own so lets wait a bit and see what happens.
Peter Singer, a philosopher opposed to screening in a recent NY Times article, was the founder of the animal liberation movement, and a proponent of infanticide and euthanasia. It's a package that devalues the worth of individual human life, using the argument that there aren't enough resources to treat us all, so let's start weeding people out based on the "odds" as applied to masses of people, rather than let's evaluate each person, look at the odds, and try to maximize their options.

Lee Smith


Lee Smith

Michael Kirsch, M.D. said...

Regarding the above comments, there is no 'God playing' here. I am simply stating that this specific screening test fails in its mission. To be effective, a screening test must be inexpensive, acceptable to the public, accurate and most importantly, it must detect a condition when intervention would make a meaningful difference for patients. There are many cancers that cannot be effectively screened because there exists no test that can meet these requirements. This is why folks are not routinely screened against pancreatic cancer, for example. Colonoscopy, however, is widely advocated because it can detect and remove benign polyps before they have an opportunity to become malignant. There may be no effective screening test for prostate cancer at this time. Keep in mind that the majority of prostate cancers will never cause illness. If an effective screening tool were devised, it would have to target those specific cancers that hare likely to cause harm.

Anonymous said...

Certainly it would be ideal to have a perfect tool that predicts with 100% accuracy the future of one's cancer. But saying the majority will never cause illness is unacceptable to me, since we minorities deserve some condiration as well. Have you studied the latest in PSA analysis, and predictions based on PSA, biopsy etc, and the role of active surveillance? The field has advanced far beyond your experience as a "skeptical medical student" 25 years ago, and even your advice to your father 10 years. Please go and study the major advances in detection, prediction, and treatment of prostate cancer and then come back and give us a considered and educated opinion.
And what about mammography --- that's next on the list of screenings being attacked.
Lee Smith
PhD, Biomedical Engineering

Evinx said...

I am not a physician - just a patient. I have tried to discuss this with several drs and each time, they insist on the PSA test. Here are their reasons (stated or non-stated):

1) They worry if they do not order the test + ultimately you get prostate cancer, here comes a lawsuit.

2) Many drs tend to view every possibility with equal probability (and so do most patients). In other words, they will order a test regardless of the probabilty you have the condition be it 1 in 100 or 1 in 100,000.

3) Many drs beieve some information is better than none - so they order the PSA test + we can discuss the results later (this is what they always tell me).

4) Much of these over-prescribed tests are the result of 3rd party payment. If we, as individuals had to pay for the tests ourselves, we would do our own implicit cost/benefit analysis. Bcs some insurance co is paying, why not have the test. Unfortunately, that is the drs attitude + the patients. Personally, I have an HSA acct with a $5000 deductible policy - so I watch the bills and the tests, etc.

5) I've been examined by one of the dr's who writes medical columns + is "well respected" - but not my me. I asked him about false positives on a test as well as false negatives. First he was defensive I questioned him. Second, he argued that even if I had zero symptoms + the test had a 51% accuracy rate, I should take it. In other words, let's flip a coin + that information will be medically helpful. Puh-lease!

I appreciate your point of view Dr Kirsch, but I assure you as a lay patient, drs just don't want to listen to lay patients - but they would if we were paying (or at least in charge of the remittance) as opposed to a 3rd party.

Thanks for this post.

Anonymous said...

It seems to me that what should be criticized is treating all potential patients as if they were the same, i.e. the statistical average, on the one hand, and patients over-reliance on the comments of a single MD, and unwillingness/inability to try to master the literature and get a feel for a range of options. Fright and ignorance are what need to be overcome. Screening undoubtedly tells us things, PSA tests undoubtedly do. The problem is what comes next. Here is where the system is failing, Docs have no time for patients, patients have no background in understanding etc etc. Rules: Get screened -- PSA for men over 40 as per AUA --- never go to a doctors office alone if you are discussing things which potentially could effect your life, read up before you go, bring a tape recorder, get a second opinion, search the web and the library for the latest conclusions and controversies, and find discussion groups for folks in situations similar to yours. Get the NCCN guidelines re your disease, figure out how best to estimate your likelihood of survival, recurrence, spread. Try to focus on what applies to you as an individual, but DONT, under any circumstances use blogs such as this as a rationalization for avoiding PSA screening. Your life may depend on it.

Michael Kirsch, M.D. said...

To the commenter who admonished me to be more current, and not rely upon my prior experience as a 'skeptical medical student', please note that my posting included reference to a large, high quality study in the New England Journal of Medicine published in 2009. I believe this is current enough.

Patients are entitled to hear their physicians explain the advantages and the drawbacks of any test or treatment, including the PSA. If this right is not satisfied, then I would not consent to the test being offered.

I agree that I would not rely upon this blog for personal medical advice. I do hope, however, that it can serve as a catalyst for patients and their physicians to dialogue better, as well as to encourage patients to become better informed about the murky medical world.

NCMan said...

Hello Michael, how can we contact you? If you can would you please contact Emaxhealth.com at info@emaxhealth.com

Thank you

Anonymous said...

re the New England Jnl of Medicine: have you read all the commentary on it:

Here is what Dr. Patrick Walsh had to say, among other things (see www.drcatalona.com):

"First, the positive trial was a landmark study carried out in seven European countries that studied 162,000 men who were randomized to PSA screening every four years versus no screening.1 With long-term follow up out to fourteen years, there was a 20% decrease in deaths from prostate cancer in the group of men assigned to screening. However, since only 85% of these patients actually underwent screening, if one includes only the men who were actually tested, the decrease in prostate cancer deaths is 27%.

This reduction in death from prostate cancer is similar to the 30% reduction in mortality from breast cancer in women who undergo mammography and the 33% reduction in prostate cancer mortality that occurred in the United States between 1994 and 2003 following the introduction of PSA screening. Thus, the results from the European study support other findings and unequivocally demonstrate that PSA testing can save lives."

As far as the US study, Dr. Walsh points out:

"What’s the problem with the study carried out in the United States? First, it did not test screening versus no screening – it just compared more screening versus a little less screening. In the screening arm, 85% of patients underwent PSA testing compared to 52% in the controls. That’s right, only a 33% difference!"

If you want to be objective, please read and analyze all of the commentary on the studies, the letters to the editor, etc etc. Also please compare the kind of treatment the subjects in PSA studies obtained to the current state of the art! You will find a big difference.

So I think I have to ask, are you predisposed to studies which minimize the effectiveness of PSA screening?

Admission: PSA screening probably saved my life, or at least years of treatment for an invasived cancer, as a fairly agressive cancer was discovered which was about to leave my prostate. There are lots of men out there like me -- to you we are anecdotal, to our wives, children, grandchildren, we are loving family members whom your approach would minimally sentence to horrible years of fighting cancer. I'd rather give up erections and have an occassional bout of wet underwear. True not all men would make my choice, but eliminating PSA screening would eliminate our ability to make that choice.

Anonymous said...

I should add, I agree with you 1000% that MD's need to discuss these things with there patients. Apparently they are not allowed to spend their time that way? Why? But if I understand you --- you are not really discussing it either-- just giving the con's and recommending against PSA tests. Please correct me if I am wrong but your posts seem very one sided, anti PSA testing, to me. That's not fair disclosure either in my humble opinion.

Michael Kirsch, M.D. said...

To the above anonymous commenter,I have absolutely no doubt, and have written in the post, that PSA has saved lives. I certainly hope that you are one of them. My argument with this screening test, based on accumulated medical evidence, saves so few and harms so many. I think that if men were given a fair presentation of PSA and its performance, and understood the natural history of prostate cancer, that many would opt against having screening done. I would be one of them. If an individual decides to proceed with PSA testing, I support this only if this individual has been fully informed. In most cases, I doubt that this necessary conversation occurs. While you suggest that I am biased, I believe that the bulk of medical evidence is on my side on this issue. Nevertheless, I respect your view. Finally, as I am a gastroenterologist, I do not offer PSA testing in my practice.

Anonymous said...

All I can say in closing is that I don't think you have the evidence to support your view on what reasonably well educated, albeit not MDs, men and women want. I know a number of fairly well educated men, all PHDs at a research university -- engineers, mathematicians, psychologists. We all read about screening we all had problematic PSAs, we all had biopsies showing cancer, we all read the odds, the tables, and so on, and we all had prostatectomies, survived with relatively minimal if undesirable side effects, and are walking around today. Can there be bodies of men who have been steamrollered into unnecessary treatments based on misunderstandings -- perhaps but that is not my experience by any means nor have I met any such men. Similarly for DCIS --- I now some physicians are tearing their hair out trying to understand why women are getting these " overtreatments" -- Mastectomies, even double Mastectomies. First the blamed the old fashioned Dr's, then the ignorant women, but perhaps finally they are coming around to understand the women and their husbands have studied the literature, and simply want to minimize chances of recurrence. We all have to die sometime, and will die when our time has come but it goes against the human spirit to prevent us or even discourage us from learnng what we can and ultimately deciding for ourselves what to do with the information. Why in the world would anyone not want screeniing --- it clearly gives information. What is at issue is what to do with it, not to stick one's head in the sand. I've seen the articles, I've seen the data -- it doesn't make sense to avoid screening --- it absolutely provides information that one wouldn't have without it --- just as it doesn't make sense to jump into treatment based on a PSA reading.

Anonymous said...

Did I miss your blog on stopping the "colonoscopy train"?

Study Suggests Physicians Overperform Surveillance Colonoscopies
Physicians appear to be performing surveillance colonoscopies at frequencies higher than those recommended by evidence-based medical guidelines, according to results of a survey conducted by the National Cancer Institute (NCI), part of the National Institutes of Health. Surveillance colonoscopies are follow-up colonoscopies given to patients who already have had a colorectal abnormality detected and removed. These results, which appear in the August 17, 2004, Annals of Internal Medicine*, suggest that as the demand for colonoscopies in the United States increases, overperformance could use up limited physician resources and cause unnecessary risk to the patients.


Surgical Removal Of Small Colon Polyps Is Costly And Unnecessary, Study Suggests
ScienceDaily (Nov. 3, 2008) — Polypectomy (the surgical removal of polyps by colonoscopy) of small polyps found during CT colonography is costly and unnecessary according to a study performed at the University of Wisconsin School of Medicine and Public Health in Madison, WI.


Colonoscopy Every 20 Years Sufficient for Early Cancer Detection?

For early colon cancer detection, experts recommend to have a colonoscopy every ten years, provided no precancerous growths are found. Results of a study conducted by Professor Hermann Brenner of the Division of Clinical Epidemiology and Aging Research of the German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ) suggest that much longer intervals may be sufficient.


the authors estimated that 2.85 million unnecessary colonoscopies would be performed over the next 10 years, leading to $3.4 billion in direct medical costs, 14,299 serious complications, and 142 deaths.

Lee Smith

Michael Kirsch, M.D. said...

If another medical specialty, such as my own, is practicing beyond the medical evidence, this does not dilute my PSA argument. Is your point that if GI physicians perform excessive numbers of procedures that it strengthens the value of PSA testing? Why not invoke car mechanics who perform unnecessary repairs? What's the relevance?

In fact, I have written about GI physicians who are practicing 'above and beyond' what we should. Here's the link if you would like to review. http://www.nature.com/ajg/journal/v104/n7/full/ajg2009340a.html

Anonymous said...

Nice article. I hope you will focus on creating appropriate reforms in practices in your field where you are obviously well versed and most likely to be effective. As far as PSA testing I wonder if your conclusions, which haven't changed in decades, are not simply just out of date. Fortunately the American Urological Association appears to have taken a number of steps in the direction you are recommending ---not eliminating PSA testing but rather refining and focusing it's appropriate use. For example in the recent:

American Urological Association Best Practice Statement 2009

http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf

“the age for obtaining a baseline PSA has been lowered to 40 years. Secondly, the current
policy no longer recommends a single, threshold value of PSA which should prompt prostate biopsy. Rather, the decision to proceed to prostate biopsy should be based primarily on PSA and Digital Rectal Examination (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. In addition, although recently published trials show different results with regard to the impact of prostate cancer screening on mortality, both suggest that prostate cancer screening leads to overdetection and overtreatment of some patients. Therefore, the AUA strongly supports that men be informed of the risks and benefits of prostate cancer screening before biopsy and the option of active surveillance in lieu of immediate treatment for certain men newly diagnosed with prostate cancer.”

If I could be so bold as to give you some advice, I would recommend that you read the above monograph, as well as the NCCN 2009 statement on Prostate Cancer before deciding to avoid PSA testing and certainly before you suggest to anyone else that they avoid PSA testing.

Lee Smith

Evinx said...

Mr. Smith
I understand this is a very personal issue for you; but, all Dr Kirsch is stating is that patients and drs ought to have the discussion PRIOR to ordering the test (before emotions get involved). What is wrong with that? As they used to say years ago, "my body, my choice." Surely (I hope) you are not advocating that the govt mandate PSA tests for all men regardless of their wishes?

Anonymous said...

Evinx: I'm not sure what Dr. Kirsch is recommending but I think the AUA approach is the way to go. As for me were a man to ask me, I would recommend PSA screening and also give him (and his significant other) things to read -- concerning the possibility of overtreatment and the possibility of invasive prostate cancer. I just don't see why one would not get screened with biopsy followup if appropriate, but I don't think the government mandates much in the way of medical treatment or screening, but they do or can require insurance companies to cover it which I think is appropriate.

Lee Smith

Anonymous said...

I should add that you are correct that I take in personally -- I apply the golden rule which is why I blabber on about this. Had I been unfortunate enough to read this blog in 1956, then when my wife asked me if I had a recent PSA reading (I must admit I had missed it along with my physical checkup for several years) I would have said "what for" being someone who likes to avoid Dr's, assume that "it can't happen to me" and be oblivious to threats to my health. Too many men that I know just don't want to deal with these things-- and will use this sort of controversy as a way to avoid going to their Dr's (until it's too late).

Lee Smith

Anonymous said...

Dr. Kirsch,

Since the issue of colonoscopies came up, I would like to ask a question. My family physician is recommending a colonoscopy because I just turned 50. Do you consider this worthwhile or superfluous at this age? If the latter, then what age, if any, should one have a colonoscopy? Thank you.

Evinx said...

To add to the Anonymous question above, what is your recommendation if there is no family history, no symptoms (including neg Hemocult tests)? Can it be delayed till age 60, 65, or even omitted?

Also, what are the statistics in the above scenario to find a cancerous polyp and what percentage of people end up with complications (perforated colons, etc) bcs of the colonoscopy?

thanks

Michael Kirsch, M.D. said...

This is a general comment, not directed as medical advice to any individual. Screening colonoscopy is advised at age 50, or earlier if additional risk factors are present. Pre-cancerous polyps are found in about 25% of males and 15% of females over the age of 50. The complication rate for colonoscopy is less than 1%. Keep in mind that the term 'screening test' means that there are no symptoms present.

Anonymous said...

As far as PSA screening, it's costs and effectiveness, there are many sides to this discussion as can be seen in the blogs below which are more more positive about the overall effects of PSA screening than Dr. Kirsch:

http://repository.upenn.edu/cgi/viewcontent.cgi?article=1010&context=psc_working_papers

"We have demonstrated that mortality reductions from prostate cancer have been exceptionally rapid in the United States and that these decline are significantly faster than among a set of peer countries. We have argued that the rapid uptake of PSA testing in the United States after 1986, together with aggressive therapeutic regimes, is responsible for the exceptionally rapid decline in mortality. Trends in disease incidence and survival after diagnosis support this interpretation. It appears that the US medical care system has worked effectively to reduce mortality from this important cause of death.

Implications for the costs of PSA screening and mammography are discussed in the blog below which suggests that we are getting “our monies worth”:

http://www.becker-posner-blog.com/archives/2009/07/mortality_from.html

Evinx said...

Anonymous
Do not think mortality should be the ONLY parameter to gauge the cost/benefit. Of course, mortality will go down if you test a majority of the universe of subjects.

I ask myself, if I am diagnosed with Prostate cancer, what are the odds it will kill me + when. Then, what are the odds of a serious complication from the treatment. And since I have a high deductibe insurance policy with an HSA, I always look at costs.

If for example, the possibility of dying from prostate cancer within say 10 years is 2% + the probability of having serious complications is 25%, then I am not doing the treatment regardless of cost.

If the complication percentage is say 5% and the cost of treatment is say $150,000, I still won't do it (I am 65) given my age. So, yes there will be rationing but it is my choice (self-rationing) which is what reform should be about.

Our health care Problem centers around cost and to most people cost is never a factor bcs it has virtually zero effect on them (bcs of 3rd pary payment). That is the core of the problem. Look at Lasik (not covered by insurance) + you will see costs have dropped dramatically over time + technology has kept on improving. The reason is market forces bcs the patient is making their own implicit cost/benefit analysis.

Michael Kirsch, M.D. said...

To Evinx, you are a highly skilled patient and I appreciate your sober and rational analysis.

Anonymous said...

I don't see medical insurance as the core of the problem. Most folks I know have worked hard and long to obtain the insurance coverage they have and now folks like you apparently want to take it away from us. We earned it, more so than MD's have earned their millions in my opinion. If this is what health care reform means -- I'm against it.

Today I went to religious services -- I happen to be Jewish and today was Tisha B'Av. We just made a minyon tonight -- the 10 adults needed to have a community service. The 10th was a young man who just graduated from college and has spent 90% of his life as a quadrapalegic in a wheel chair with a breathing machine. It's miracles like this that you calculations would deny us. Take away the miracles and what do we have ....

Anonymous said...

Evinx asks: "Surely (I hope) you are not advocating that the govt mandate PSA tests for all men regardless of their wishes?" Actually I hadn't really thought of that but how about the following rational and cost serving measure: men who chose not to get PSA tests (and follow ups when appropriate) will have limited or no coverage for their treatment should they have the misfortune to develop invasive prostate cancer. Why should society pay for men who chose to bury their heads in the sand?

Lee Smith

Michael Kirsch, M.D. said...

Careful here Lee. Your reasoning, if extended, could lead to some unintended effects. Under your construct, what happens if overweight individuals refuse to lose weight and suffer medical consequences? Do they lose insurance coverage for the resultant illnesses? What if someone does not perform aerobic exercises three times weekly? What if someone's diet is rich in saturated and trans fats? If they develop heart disease, should they pay personally? I think that your suggestion is more defensible when an individual's behavior is reckless and society bears the consequences, such as a motorcyclist who won't wear a helmet and is injured.

Anonymous said...

I would claim that avoiding PSA testing is almost equivalent to not wearing a helmet on a motorcycle.

Hopefully Senator Dodd's treatment for prostate cancer will go well, and he will serve as an example of the benefits of PSA testing.

Lee Smith

Michael Kirsch, M.D. said...

Lee, I disagree. It is accepted as fact that wearing a helmet while on a bicycle or motorcycle reduces the risk of serious head injury. In addition, I am not aware that helmet wearing has risks or can lead to a harmful event. Repectfully, the PSA analogy does not work.

Anonymous said...

A quick search of the Web will reveal that there are data that show that a helmet interferes with vision and with hearing and that this can actually increase the changes of an accident. Do you know of evidence based studies, with human beings that show that their are no risks to wearing a helmet, that life expectancy is increased etc.
Lee

Anonymous said...

An interesting website was cited above (drcatalona.com). It should be visited by all men concerned with prostate cancer, i.e. all men. Here is what Dr. Walsh concludes in an article on that site:

"If you are the kind of person who doesn’t wear a seat belt nor goes regularly to the dentist or your family doctor for a check-up and are not worried about dying from prostate cancer,

and doesn't wear a helmet on a motorcycle (my addition)

do not undergo PSA testing. On the other hand if you are a healthy man age 55-69 who does not want to die from prostate cancer, the European trial provides conclusive evidence that PSA testing can save your life."

Lee

Anonymous said...

Like most discussions of the pros and cons of PSA testing, there is little mention of the ravages of prostate cancer. So to get back to reality, here is a horrifying example of what can happen if your Dr, like many in Great Britain, downplays or recommends against PSA screening:

http://www.dailymail.co.uk/health/article-1204121/The-7-test-saved-husband--scandal-men-arent-told-it.html

Michael Kirsch, M.D. said...

Obviously, there are patients and physicians who worship the PSA screening test. I am not one of them. My primary objection is that the majority of men who undergo this screening test are not adequately informed about the risks and benefits of the test as well as the natural history or prostate cancer, usually a silent disease. If a man knows the full story, and wants to proceed with PSA testing, then I support his decision.

Anonymous said...

I'm all for "full disclosure" so long as it includes risks of not being screened and then having a cancer that leaves the prostate. The problem is of course that avoiding PSA testing and biopsy if indicated will provide zero information from which no estimates of future development can be drawn. THis ignorance cannot be the best approach, nor can simply jumping to treatment based on a PSA reading which no doubt is contaminating many of the studies. One is only "usual" which means no cancer until one is stricken, and there are so many men with prostate cancer that it seems to me that ignorance is a dangerous route to recommend. Once one gets a full range of PSA testing and biopsy one can get an individual prediction of likely outcomes and then an make an individual decision. Saying NO to PSA testing eliminates individualized medicine focused on one as an individual. Treatment based on mass statitistics is unfortunately what the future holds so that the unusual 10, 20, 30 % will suffer in ignorance from a preventable disease.

Anonymous said...

Wow, it turns out that SO SO many of the "advances" in medicine have no basis in reality. Dr. Mark Hyman goes down the list from statins to mammography and everything in between.

http://www.huffingtonpost.com/dr-mark-hyman/why-health-care-reform-wi_b_248937.html

What is wrong with our medical system and the money hungry MDs that are produced? Let's let a panel of objective and ethical medical experts such as yourself and Dr. Hyman come up with a list of questionable procedures, etc. Then anyone who wants any treatment or procedure on the list needs to enroll in a double blind study where they are put in either a test or control group and we will see which group produces more disease and deaths.

Anonymous said...

Dr. Kirsch,
You are wrong. It is better to test the whole world if one life is saved. A close relative whom I love deeply has had an additional 9 years (and counting, now that his aggressive prostate CA has returned and metastized) because his diligent PCP ran the PSA test and referred him to a diligent Urologist.

What is a human life worth?

I refer you to the Jewish philosophy of Pikuach Nefesh. No test is unnecessary or too expensive if it will save one human life.

Please, sir, what is your opinion of the death penalty? Euthanasia? Eugenics?

Comparative Effectiveness is YOUR slippery slope.

Michael Kirsch, M.D. said...

To the anonymous commenter above. I am familiar with the principle of pikuach nefesh in Judaism, which places an overriding priority on saving life. I am reluctant to endorse your believe that "it is better to test the whole world if one life is saved". If global testing results in hundreds or thousands of casualties, for example, then would this effort be worth saving a single life?

nuclearfire said...

Wow. Dr. Kirsch, you are unbelievably patient.

For some more expert perspective (current as of May 26, 2009):
1) The United States Preventive Services Task Force (USPSTF) states that there is not enough evidence to recommend for or against testing in those under 75, and recommend against testing in those over 75 due to harm.
2) The Canadian Task Force on Preventive Health Care recommends against testing due to insufficient evidence.
3) The EU recommends against testing until more randomized trials are complete.
4) The American Cancer Society recommend discussing the risks/benefits with the patient (uh, duh) and offering them the test. They recommend doing it if the patient asks the doctor to make the choice.
5) Ditto for the American Urological Association (AUA).
6) The American College of Physicians (ACP) recommendation states that "Rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient's concerns; and then individualize the decision to screen"

And for all these happy people who I think have never actually cared for a patient, one of the complications of surgery is death and I've had a patient die on the table during the surgery. The autopsy showed the cancer to be a non-invasive type that would not likely have ever been discovered but for some random PSA testing. What you seem to not understand is that the choice is not between money/time vs. illness and death but between money/time/death vs. money/time/death. The point is to figure out what choice is best for all three and until we know the answer, responsible physicians don't just push a test without disclosing to their patients the facts. The point is that there is not strong evidence that the test does in fact save lives. Great, it saved yours; it cost someone else's; I'd gladly have traded my patient's life for yours and I bet you feel the opposite. If it was so great and so clear cut, don't you think the evidence would be more rigorous and the advisory committees in a little more agreement?

Evinx said...

I believe the Anonymous commenter above is mistaken on his interpretation of the concept of Pikuach Nefesh.

P/N applies to a specific person - it is not to save mankind.

Regardless, the US is not a theocracy. It cannot have its govt policies based on religious law - not Judiasm, not Sharia, + not Catholic. We as individuals are free to practice our religious beliefs as we see fit and physcians must be so included. Can you imagine the outcry - and the long term consequences - if the Pres or Congressmen stated our healthcare policy must be derived from P/N?

Finally, it is one thing to be charitable and completely another to have a Robin Hood philosophy (regarding healthcare or other issues) when you are taking money from one person to pay for another -- particularly when the one you are taking from may be a child or may not even been born yet. Where is the morality in that?

Anonymous said...

According to the Talmud:

• whoever saves a life, it is considered as if he saved an entire world.
- Babylonian Talmud, Sanhedrin 4:8 (37a)

This was quoted to me 12 years ago by a urologist who had just given me the results of a second PSA test. I had no symptoms that I was aware of, it was a routine screening, and he was concerned and recommended a biopsy. Can you realy assert that I was in any way harmed by getting to that point. That is SO ridiculous. I didn’t have to do anything in the way of symptoms but a biopsy seemed the way to go given my PSA reading. What harm was there, to me or society, in taking that next step? The majority of cores showed malignancy -- fairly aggressive and close to th edge – I don’t remember the number. He told me of options: “watchful waiting”, surgery, radiation, cryosurgery, seeds. I began reading up on this stuff. He gave me some material, I spoke to colleagues at the University who dealt with these issues, I discussed this all with my wife. I read Dr. Walsh's book, I looked at the Partin Tables, and I prayed that Yom Kippour. The prayers took on new significance, especially the phrase “who shall live and who shall die” in the coming year. Perhaps none of this is in our hands, but if it is, it's up to us to gather all the data we can and make the best decisions we can -- not by ignoring potential evidence and clearly the PSA test provides such evidence even if uncertain evidence

I would assert that it was my inalienable right to reach that point, to gather all the information I could, and to make the best informed decision about what path to take. I was standing at a series of doorways but without routine PSA screening I would have been blind to the options facing me. How can anyone in his or her right mind claim I would have been better off not reaching that point – it defies logic and morality, let alone Judaism in my humble opinion. So – did God answer me, was it my medical advisors, my intellect in trying to digest the literature? I’ll never know but I chose a radical prostectectomy and till now, thank God and my surgeon, there is no evidence of cancer spreading. I realize had I done absolutely nothing perhaps I would have never known, spent less on replacing underware, and have better erections. On the other hand perhaps I would have spent the last number of years fighting a spreading prostate cancer. But that’s not a risk I would have wanted to take given the odds based on studies involving the specifics of discovery and diagnosis, not hugh impersonal indiscriminate studies which provided no specific information re my situation.

Twelve years later there are more nuanced PSA tests, more aggressive active surveillance protocols (replacing watchful waiting – what would one wait for in those days) and less invasive successful treatments, so as far as I can see it any man who avoids PSA testing (and spouses you too if you don ‘t aggressively pursue your partners) is simply out of his mind. I don’t get it.

Lee Smith said...

Anonymous: What you don’t realize is that you are an exception, an anecdote, a lucky fluke. Most men are ignorant, most Dr.s are greedy pigs. So you get a PSA reading above some threshold, and off you go to aggressive overtreatment. Cut out the PSA reading and this whole sequence is cut off. Of course there is another approach, education and common sense but let’s face it, the majority of us don’t have access to these approaches, no one has time or ability to educate us, so the only way is no PSA!

Anonymous said...

NCCN has just published a new report on PSA testing. I would strongly recommend that you read the report (and not depend on the brief press releases which don't do justice to the report) especially the list of a dozen or so points that men should discuss with their physicians in order to try to understand the pros and cons of PSA testing. The report is available at no charge although you may have to register to get it. Try the following website:

http://www.nccn.org/professionals/physician_gls/PDF/prostate_detection.pdf

Anonymous said...

It seems to me that there is too much rhetoric and not enough information in current discussions of PSA testing. One or two sentences on the NEJM studies is nothing I would want to bet my life on.

Why isn't there more discussion of predictive tools, based on PSA and biopsy, which can then guide decisions. For example (and there are others) the Memorial Sloan Kettering algorithm:

http://www.mskcc.org/applications/nomograms/Prostate/index.aspx

Based on these numbers one can begin to interpret results and decide whether or not to move on with treatment. Thats the logical thing to do, isn't it.

Anonymous said...

Quoting some statistics showing that there are belatedly a few more medical schools opening up (after years of deliberate undersupply) proves nothing. The fact is, more qualified graduates than ever are being turned away from medical school for the sole reason of keeping doctors incomes high.

Its time for the silent majority of Americans to rise up against this closed shop that all of them pay for. Let the qualified graduates in to be doctors, and finally take on the doctors, the USA's most powerful union.

See here for more:
http://wallstreetpit.com/5769-the-medical-cartel-why-are-md-salaries-so-high

Lee Smith said...

The answer is not to stop the PSA train, it's to move on to active surveillance (AS) when necessary. This does take work and individualized attention, not mass statistics. It's of course easier to say "No PSA" or to say "out with the Prostate" but the challenge is to find the right person to help each afflicted individual find the proper path. In the words of one experienced expert:

"An individualized plan for early detection management of low-risk prostate cancer that balances patient risk with treatment morbidity and survival benefit can circumvent the conundrum of overdiagnosis through the selective use of active AS."

Anonymous said...

My husband, 69, had a 4psa. Something about the test caused him worry instead of wait so he had a biopsy. Although the first biopsy left him bleeding considerably for two weeks the results were normal. His next bloodwork check up his psa was higher so another biopsy which indicated a typical one area. The next psa check up the psa was a 10 so another biopsy and the a typical area was malignant. Following that biopsy the psa was 15. I can't help but think he might have been better to wait at the number 4, considering nothing about all of this was helping the circumstances and likely harming. So, he is waiting and watching and maybe it would have been better to wait and watch at a four instead of the invasions.

Now my dad, 84, goes for a regular check up and the lady does a psa and manual exam but doesn't feel anything. She tells him it is optional but tries to set him up with a urologist at the clinic. Finally I go online and determine the clinic is offering free psa testing so an aggressive campaign. I read the reason it became known old men were dying with prostate cancer which didn't kill them, meaning many old mean have prostate cancer to some degree, and then suddenly there is the psa, considered unreliable but?... So, knowing many older men have a little prostate cancer that is a good testing area, even though the prostate cancer probaby would not have killed. So, the prostate area sounds like a sure shot at finding something someone could have that might not have been a problem but a legitimate way to test, biopsy, and treat.

I am actually curious if the biopsy itself causes harm. How do you sort through all of this anyway? Now, my husband is getting signed up for robotic and my dad decided to refrain from the urology visit for now. I need help. My husband has started taking valium to cope and my nerves are shot worrying they almost had my dad into the drama. What do I do about my dad. His bloodwork papers are suppose to arrive in the mail. I think he probably has an enlarged prostate knowing my grandfather did. Like the routine looking for cavities at the dental office every six months and people ending up with a mouthful of fillings and crowns they don't need, what is the best way to survive the medical world? Help, taylors234@aol.com

Anonymous said...

Although I did not have time to do an extensive search, I searched dates and it appears prostate cancer increased in the 1980's and it was in the 1980's that the psa testing started? I am trying to determine the timeline to evaluate if prostate cancer actually became more of a problem after the psa testing came along? During my earlier readings I have not noticed anyone putting together the dateline and statistics of the rise in prostate cancer, second leading killer?, and the psa testing. It appeared to me that there were fewer prostate cancer deaths before the psa testing began? Is it possible there is a connection and the testing, biopsy itself, can cause cancer to spread? I have read some debate about that possibility with some indication there is a possibility and the other stating the risk is worth taking... If true, are people informed there could be a risk to biopsy?, or there is not enough proven evidence to mention? I think if someone better at this than I am would look at the rate of death from prostate cancer before the psa testing, screening, began and determine if there is actually a rise and how much? Please help. Patricia

Erich S. said...

Hi Patricia,
The last I read, there was a rise of prostate cancer *diagnosis* with the introduction of the PSA test. People with a "high" PSA opted for biopsies, many of which confirmed cancers that never would have been discovered or ever have bothered the patient otherwise.

I have seen a query elsewhere asking if biopsies of prostate-confined cancer might cause it to spread through cancer cells getting into the bloodstream when the needle is extracted. Does anyone know the risks of it, if any, or for that matter from cancer cell release from the prostate through the loss of prostate capsule integrity caused by the biopsy?

Anonymous said...

One night soon I will try to find the detailed write up but there was something about several nicks to an area and then the blood leaking into the other nicked areas...

Another site where regular people worried there was someone asking about dragging cancerous cells through the rectum.

Just to contribute some finding after some extensive searching there is some question why there is so little prostate cancer in India and China. There are theories. One involves the use of a spice tumeric in India. China claims it's study did not find licopene, such as in tomato, to be as helpful as other findings. China claims garlic and onion to be more helpful. Some studies indicate brocolli and cauliflower, etc. etc. ohhhhhhh but

Saw palmetto is more consistently reported as helpful for prostate without argument.

There was one site where a man claimed cottage cheese and flaxseed oil will benefit or perhaps he suggested reverse prostate cancer. That might sound odd but supposedly people who have prostate cancer were determined by blood test to be low in the Omega and the cottage cheese was brought into the picture by a woman in Germany who found or thought she found the sulpur protein? in the cottage cheese somehow carried or aided the flaxseed oil to???? I don't have this copied and it has been a while since I read the info but supposedly yogart could be used instead of the cottage cheese but eating more yogart than cottage cheese would be required.

I think trying some saw palmetto or cottage cheese and flaxseed oil sounds like a winner in the beginning on some of the psa number leading to biopsy. For instance, with a psa 4 sounds like a time to try something instead of the biopsy which leads to higher psa itself and then more testing. In other words, the wait and see in the beginning if there are some diet or other options to try rather than the wait and see after a higher psa, some of which is the result of the biopsy and after the blood has been flowing, just in case.

Hey, I hope for miracles but after hearing about the first biopsy on a psa 4 maybe that is not too crazy. The first biopsy on a psa 4 led to seeing a lot of blood for two weeks. If there is some chance something is there that can spread and won't be a good thing I would prefer the saw palmetto and the wait and see at that point rather than wait and see after a few biopsies and the number up to a 15.

Also, it is unclear if the psa testing has been going on in the same type way in China and India. If not, could that suggest the reason prostate cancer is not the number 2 killer in India is because they are not tested and having biopsies and treatment or just because there is something otherwise significant. I don't know but from what I read it sounds like an attempt to get probotics into India so maybe check back and look at the statistics in India in the future.

Oh, there is also vitamin d research suggesting lack of sun which might give the people who promote Natural Hygiene some recognition. They suggest putting all body parts in the sunlight.

For now, this learning experience continues.

Patricia

Anonymous said...

Dr Budwig discovered that when she combined Flaxseed oil, with its’ powerful healing nature of essential electron rich unsaturated fats, and cottage cheese, which is rich in sulfur protein, the chemical reaction produced makes the oil water soluble and easily absorbed into the cell membrane.

This is what I was trying to explain in the above comment regarding the cottage cheese and flaxseed oil.

I don't know if it works but my husband is putting it to the test somewhat. He is not mixing the flaxseed oil with the cottage cheese because whoever brought him the flaxseed brought pill form. I do not like the idea of taking pill form of anything but he plans to buy the actual flaxseed Tuesday. He is also including the saw palmetto? sp? in his diet so sorting throught which is actually helping is more difficult. He says he notices quite a difference since adding these substances but I am unsure the specifics.

Anonymous said...

THANKS FOR YOUR ARTICLE! WE DID A DOCUMENTARY CALLED "THE SECOND OPINION" ARGUING THE VALIDITY OF THE PSA TEST. WE INTERVIEWED THE SCIENTIST WHO DISCOVERED PSA AND CLEARLY STATES IT IS NOT "CANCER SPECIFIC" AND THE PSA TEST IS BORDERLINE "CRIMINAL"! WE ALSO INTERVIEWED MEN WHO WERE AND WERE NOT TREATED BECAUSE OF HIGH PSA #'S AND WHO TALK CANDIDLY ABOUT THE AFTER EFFECTS OF INCONTINENCE AND IMPOTENCE FROM TREATMENTS.

Anonymous said...

Oh, I was tired and didn't write enough above but anyone to try the flaxseed and cottage cheese needs to read the information online, which is more than I wrote last night. Do not eat sugar, white or brown, or preserved meats, margarine, etc. Really the diet is simple by using squeezed grape juice or other fruit juice for sweetner, or honey. There is a little more to know but easily picked up by reading about Dr. Budwig online. I am not advocating but only pointing out the research I discovered online along with the pros and cons.

One notice was the Chinese said their research found onions and garlic more important than other research regarding lycopene. After reading Dr. Budwigs research it is to note onions are a sulphur food? so possibly some sulphur connection to the two unrelated researches.

I am only out here reading and reporting research I have read about online, with no degrees or expertise of any kind. My comments only offer results of search others may not have read but might like to examine.

Michael Kirsch, M.D. said...

More information from today's New York Times supporting the Whistleblower. http://bit.ly/3UdKOp

Anonymous said...

This has been interesting reading. I am not as well educated as some of you are, just a lay person who thinks that CHOICE is what I have as a patient. So then, it seems to me that the government and those in the medical field need to work together to allow people with choice to get what they want or don't want. I have been fortunate to have doctors who informed me enough to choose whether to have a procedure or not. They gave the information and did nothing more to influence my choice to their way of thinking. When legislation of any kind diminishes my ability to choose, then that is freedom lost. That loss is unacceptable to me. Nevertheless, thanks for all the information.

Anonymous said...

another search notice is that supposedly vitamin B6 is getting strong reviews for keeping prostate cancer under control.

As for second opinions........... ohhhhhh well, biopsy initially sounds innocent or harmless somehow. First there is alarm and then the suggestion for biopsy and people don't think 2nd opinion until the biopsy is over and the discovery the biopsy itself could be ??????????? questionable.

As for the research involving cauliflower, brocolli, tumeric, etc. I read that cauliflower and brocolli should be used in conjunction with tumeric to be effective. In conjunction there is evidence of halting tumor growth. This is just a result of reading research which I include for others to read if interested.

Oh well, we have choice but it seems to me it is easy to run one step behind when it comes to medical decisions.

My husband had another appointment. The last biopsy showed early and only affecting one area so he asked about options other than the suggested probotic removal. He was told that he could have prostate cancer all over the prostate like the guy in the next room even though the biopsy, 3rd one, showed only one area. The first biopsy was normal, the 2nd one area atypical one area, the 3rd the same atypical area cancer cells but no tumor. Now he is told it could really be all over that they don't know. So, the psa is inaccurate and the biopsy can be that inaccurate so he is led to believe there is no choice but complete removal.

He has been working on some of the alternative and will have another blood test in two weeks. His number shot up after the first biopsy, again after the 2nd biopsy and a lot more after the 3rd biopsy. His number only rises and rises with the testing so that in itself is quite confusing.

I am afraid he is on the train.

Anonymous said...

Imagine this:

Marijuana Fights Prostate Cancer


This comes as a surprise to Sandy Hutchens Cancer Prevention. Chemicals in marijuana have been found to stop prostate cancer cells from growing in the lab, suggesting that cannabis-based medicines could fight the disease in the future, scientists said.

After working initially with human cancer cell lines, Ines Diaz-Laviada and colleagues from the University of Alcala in Madrid also tested one compound on mice and discovered it produced a significant reduction in tumor growth. Their research, published in the British Journal of Cancer, underlines the growing interest in the medical use of active chemicals called cannabinoids, which are found in marijuana.

Anonymous said...

Yes, read the article in the NYT. Thank you.

Anonymous said...

anyone out there still following this thread, check out

http://www.prweb.com/releases/AUA/prostatecancer/prweb3149724.htm

Lee Smith

Anonymous said...

The company my husband worked for went under and botched his insurance so he was without coverage. He had a PSA of 6 so insurance companies used that as a reason to deny him coverage at any cost.

Five years have passed and he has had all sorts of tests and scans and there is nothing wrong with him though his test continue to be high.

Instead of a PSA test men of a certain age should go ahead and have real tests as a matter of course. It should be no different than a colonoscopy at 50. Then they wouldn't have their records marred with a meaningless black mark.

Anonymous said...

Dr. Kirsch,

Thank you for your blog posting. It is most appreciated.

Recently, a dear friend of mine visited his general practitioner in order to obtain medication for ED. Instead of receiving medication, he ended up with a PSA test and a DRE. After receiving the results from the two, he was scheduled and since received a biopsy.

He is presently 45 years old and in his early 20s had thyroid cancer, in which his thyroid was removed.

I am in a quandary to his screening for prostate cancer over ED. From what I have read, ED is not necessarily a symptom of prostate cancer. His thyroid issue might result in ED.

I am no physician and I haven't all of the appropriate information, but I find this screening unnecessary.

The screening has created more anxiety and depression. When he went to the hospital to receive he biopsy, he wanted to discuss treatments at that time. My friend is already discussing removing the prostate and radiation treatment and he hasn't even received the results from the biopsy.

He has lost a month of his life in worry, depression and anxiety. The quality of his life has literally dropped, just from receiving the screening for prostate cancer at the age of 45.

Now I might be in denial, but I sincerely don't believe that he has prostate cancer or the other diseases that it could mimic. It is greatly due to research on my part that I have found that both tests can lead to a large percentage of false-positives. In some articles I have read that it cold produce false-negatives up to one-third of the time or more.

It is my concern, not only for my friend, but also for my brother, father and son, that this could lead to a slippery slope. Men like my friend have a tendency to jump the gun for treatment that very well could lead to the loss of quality of life. I'm sure that the professionals involved will be happy to accommodate his wishes for treatment should his Gleason score be less than 5. He is an ideal candidate for over treatment, because these screenings have caused so much anxiety in him.

The physiological factors or horrific. In addition, I have read that the screening for prostate cancer carries risks that might create more problems in which is sought to be cured (ED).

Anonymous said...

THANKS! This site has been very helpful. The medical hospital lady was calling like a telemarketer trying to set my husband an appointment for prostate surgery. My husband was so worried that he was signing up but AS A RESULT of this site and the lack of a tumor, which was never discussed, we went for a 2nd opinion and determined surgery is unnecessary. My husband has only a few cells in one part of one area out of the six. Now we realize he was actually had a biopsy on a normal number the first time when he was left bleeding for two weeks. I know there are people who really need help and surgery but obviously people might be signing up for unnecessary surgery. So, all of this time my husband has been just about nuts, unable to relax, angry, etc. all leading to a case of tmj for me!!!! I continue reading and learning at this site often. Hopefully the sharing will help others. Thanks again for educating, allowing people to share and finding solutions.. Patricia

Anonymous said...

Hi Michael,
Thank you so much for the excellent article: "Stop the PSA Train! Recently, I attended an appointment with my husband who received a negative prostate biopsy result. I challenged the urologist with the results of the NEJM study and he would not engage in a discussion. Furthermore, he told my husband that he should have his PSA testing every six months and if it's high again proceed with a biopsy. We're unfortunately on the train and I want to get off but my husband is worried. The urologist said that the PSA/biopsy is just like having a regular colonoscopy. I argued that the PSA test/biopsy is much less accurate as a screening tool than a colonoscopy but he disagreed.

Can you comment on this? Thank you.

Michael Kirsch, M.D. said...

I strongly recommend that all read the editorial from today's New York Times, written by the man who discovered the P.S.A. test. http://nyti.ms/9RoVer

Anonymous said...

Luckily, no one ever dies of prostate cancer so having a diagnosis, even an imperfect one, is a waste of time.

You might try to understand your condition and spend money trying to live longer.

I think the new cost conscious message to avoid PSA testing and wait for more sever conditions to present themselves is a much better idea. Heck, you will probably die of something else anyway so why bother.

Of course now insurance companies can stop paying money for testing that is no longer recommended by a leading cancer organization.

Now if they could do the same thing for that other non-problem, women's breast cancer screening ... Oh wait, that has already been done.

Nice.

John said...

This article regarding Prostate Cancer Screening: Stop The PSA Train is very informative and useful, the prostate cancer issue can affect your sexual activity, and this not only happen to older people as I used to believed, young people can also be affected so you may need to buy generic viagra to avoid this situations. Thanks for sharing and have a nice day.

Anonymous said...

Mr. _____, an otherwise healthy and vigorous member of the community, died Monday the result of an aggressive brain tumor.....seven years following diagnosis of prostate cancer. Mr. ____chose to remain untreated for the usual reasons. Rest in Peace Dad.

Michael Kirsch, M.D. said...

Some PSA news from across the pond. http://bit.ly/gNcoWJ

Ed Dwulet said...

Just came across your great blog and this post and wondering if you've ever seen this: http://www.issuesinmedicalethics.org/043mi074.html The great American pseudo- epidemic of cancer of the prostate. Written in 1996. This guy, an m.d. and Standford Prof of medical ethics was spot on in his take on PSA testing. Why the Indian Journal and not the NEJM? Too many docs making too much money?

Michael Kirsch, M.D. said...

Getting tougher and tougher to cheerlead for PSA. http://nyti.ms/oLPKAY

We Care India said...

Cancer is a complex set of diseases. Each cancer is unique in the way it grows and develops, its chances of spreading depends on the way it affects one`s body and the symptoms one may experience . Several factors, including location and how the cancerous cells appear under the microscope, determine how cancer is diagnosed. Prostate cancer surgery India

Anonymous said...

DrK---this sounds familiar. Plenty of comments show you struck a nerve. My view----fear of lawsuits occasion all sorts of tests of dubious merit. If I read all the essays, can I receive an honorary medical degree? po




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