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Mar 6th 2015

"My GP Just Doesn't Believe in PSA"

"My GP Just Doesn't Believe in PSA"

“My GP just doesn’t believe in PSA”, a new patient told me today. He was referred to me with an elevated PSA drawn elsewhere and some subtle changes on rectal exam. Unfortunately I am starting to hear this exact refrain with greater frequency. When the US Preventative Services Task Force made PSA recommendations in 2012 the concern was that we would start to see a reduction in prostate cancer detection and ultimately see men present in the more advanced stages of the disease. At first, my own clinical experience post 2012 did not follow this. The elevated PSA consult remained a common office consult and using a multivariate approach to risk assessment I would try my best to navigate these men through their clinical decision-making. That was of course until the Canadian Task Force on Preventative Healthcare published its own recommendations in October, primarily using data based on the flawed US recommendations.

In the few short months since that time I have had numerous conversations at an individual level with many of my primary care colleagues to try and explain how prostate cancer detection is a nuanced clinical endeavor. Still, the adoption of PSA ‘non-belief’ has grown. The busy GP is far too busy to fully understand the very real differences between population wide screening and clinical detection at an individual level. Yes there is a wide gap between indolent disease and advanced disease but it requires an individual approach that takes into account known risk factors and patient desires. Certainly the idea of not doing a PSA needs to be completely discouraged. The concept of not “believing” in PSA I find entirely absurd.

The litmus test of any screening tool is that it needs to detect disease early, be cost effective and have a treatment available that alters the natural history of the disease. PSA by itself is not a great screening test. With respect to prostate cancer the challenge is that many men will not require treatment. There are clearly consequences to having a biopsy as well as potential harm created by changes in urinary and sexual function. The two task force recommendations weigh these factors heavily and discard the notion that a diagnosis of prostate cancer does not always follow a direct path to treatment.   With careful follow up and the use of newer technology such as MRI we can better stratify an individual’s cancer risk. Active surveillance for low risk disease has become widely adopted, especially here in Canada.

Let us be very clear that prostate cancer is a real disease. While up to 1 and 6 men might be diagnosed with prostate cancer in their lifetime and only 20% of these men might in fact have clinically consequential disease I would submit that still is a large number of men. As I have written many times before on this site and elsewhere, while we have some knowledge about clear risk factors such as family history and ethnicity, in my experience the large majority of men that have presented with meaningful disease have had no clear or prior risk factor. Until we get a better tool that is widely available, PSA is the best thing that we have. Certainly prostate cancer detection in a world without PSA earns a trip back to the 1970s. Understanding how to interpret it and not submit it to a one size fits all approach is what needs to be taught better. The concept of doing a baseline PSA is very important. There is no way that anybody can interpret a PSA in isolation without having a sense of where it might have been 3, 5 even 10 years ago as well as having an understanding of how the prostate feels and how large it may be. Adding to this an understanding of risk factors and patient preferences allows for a better decision-making process around biopsy. We can’t simply abandon an entire generation of men waiting for something better to come along. Those men that are destined to be harmed by prostate cancer must be found and offered a chance at cure.

 

I would call upon my fellow urologists and radiation oncologists to reach out to their local communities and speak to colleagues at a primary care level. Our understanding of prostate cancer detection is clearly imperfect but we have made strides in reducing prostate cancer mortality and if we completely abandon the one important test that we have come to rely on over the last 25 years we will court disaster. Like the current travesty with the antivaccine debate it is not good enough to simply say “I don't believe” in something when data clearly suggests otherwise. Yes, PSA is imperfect and the waters are a little muddy but understand what you are dismissing with the potential downstream harm to many men before you commit to that belief. Support the thoughtful clinical use of PSA and not abandon it wholesale. Let urologists at least have the chance to assess these men and stratify their risk

 

 

Rajiv Singal  

Twitter: @DrRKSingal

 

 

Comments

Posted: March 09, 2015

By: Ed Collis

Hey....I may be an old guy, but I wanna keep getting older.

Posted: March 09, 2015

By: Tom Little

As a Prostate Cancer survivor because of PSA testing, it is unbelievable to me that PSA testing is being abandoned. Thank you on behalf of the men it has saved and will save for keeping up the fight to maintain it until something better is available.

Posted: March 09, 2015

By: Louis Di Bianco

I'm a person whose PSA exam saved his life. It led to early detection of a cancer that was about to run wild. Dr. Singal and I took immediate action and removed my prostate. I'm happy to report that it has been almost two years, and I am cancer free.

Posted: March 09, 2015

By: Declan Murphy

Hi Rajiv,
Unfortunately we are certainly seeing and hearing this in Australia too. I did not think that the persistent negative messaging about PSA testing since 2009 would have quite the impact it now appears to be having. In Victoria (where Melbourne is located), the absolute numbers of new prostate cancers has dropped by 25% in the past five years, despite a growing and ageing population. The prostate cancers clearly have not gone away, we will obviously see these at a much later stage in coming years. I think your message that we need to speak to our primary care physicians is very important. They have been given very negative messages and we need to make sure they know that these messages will bring us back to a dark era for prostate cancer.

Declan Murphy
Urologist, Melbourne

Posted: March 09, 2015

By: John Ison

Agree completely. What real harm can come from a false positive?

Posted: March 09, 2015

By: Mike Hayes

Our medical community should be "throwing absolutely everything they have at their disposal " to promptly diagnose, treat and eventually cure this dreaded disease. Yet, we still hear of those professionals who elect to downplay or even disregard the significance of PSA testing. I have been fortunate to be under your tremendous care for over 10 years now. During that time, you were able to establish PSA baseline test results, coupled with regular examinations. When my PSA began to rise above established norms in late 2014, you performed a biopsy confirming the need for surgery which took place in January 2015 and allowed for the healing process to begin. I shutter to think what would have happened had the PSA tests been dismissed. As a thankful survivor, please keep the fight going -especially for those who may happen upon a GP who has read an ill- timed report or two. PSA testing can and will save lives!!

Posted: March 09, 2015

By: Gene Pilato

I was fortunate to have a GP that noticed my PSA elevation and referred me without hesitation. Dr.Singal recently removed my prostate and the "O" PSA result made everything so much briighter. I have stressed to my son and son-inlaws that if their GP tells them the PSA is not necessary then they should change doctors. This issue should be a no brainer.

Posted: March 10, 2015

By: Stuart Hartley

I had four annual medicals with my GP who, unbeknownst to me was not checking my PSA. When it finally became, known my prostate cancer was at a relatively advanced stage and required radical surgery (thank you Dr Singal) plus several weeks of radiation treatment at Sunnybrook. My advice to friends is find another doctor if your GP won't check your PSA each year.

Posted: March 10, 2015

By: Peter Crosby

!2.5 years after a diagnosis of prostate cancer I'm going strong. Surgery and radiation have played havoc with my urinary tract but I'd be dead without the diagnosis and intervention. So I'm good with that. The sequence for me was digital rectal exam, followed my much elevated PSA and finally biopsy where I had a Gleason number of 8. My only regret is that I skipped my annual check up for a year because my cancer was not encapsulated when Dr. Singal removed my prostate. The PSA test used intelligently in conjunction with the other diagnostic tools is an essential component of prostate cancer detection. My sons know that.

Posted: March 10, 2015

By: George Wortman

Hi Rajiv - an eloquent and persuasive article, but, I am only a layman believer with my prostrate already removed and a 0 PSA. Keep up the good fight against the mighty medical establishment. Perhaps you could enlighten us about the latest research going on to replace the PSA with something better.

Posted: March 10, 2015

By: John Axler

I just got back from 6 weeks in Mexico and was slightly exposed to their health care system. They are not at all impressed by “watchful surveillance” for an elevated PSA and a biopsy that was +ve for prostate cancer. Rolling of the eyes was the commonest response from the doctors. How widely accepted is “watchful surveillance" on a worldwide basis? I think Laurence Klotz just got the Order of Canada for promoting or maybe developing this concept in Canada but I have the impression it is not accepted worldwide.

Posted: March 12, 2015

By: Will Tinmouth

Rajiv,

Nicely put -- PSA is obviously a flawed test but I think in experienced clinical hands it has real utility. It is unfortunate that we are fighting a rearguard action based on large trials with unfortunately flawed methodology. Out here in BC we are engaging our family docs at every turn to try and turn this nihilism about PSA and DRE into a sensible risk based approach to prostate cancer screening. Some of the most difficult clinical cases I contend with involve those presenting with late stage prostate cancer and significant local symptoms.

Keep up the good work!

Will Tinmouth MD FRCSC
Urologist, Comox, Bc

Posted: March 14, 2015

By: Larry Brown, NW Ontario

Without the PSA tests I may not have survived beyond 2012. An elevated score, active bioposy in 8 pods, surgery to find the cancer which was quite active and had escaped. Radiation a year later and hormone treatments for two years has given me the prized 0 score. There are drawbacks as the process can have its own problems with the urinary tract and cause strictures, incontinence, impotence, but the flip side is the hope of living a good life for many more years. PSA's are drilled in to my family and in time a more painless approach will be developed to give us a continued enhanced quality of life.

A big thanks to all volunteers and staff.

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