Just catching up on the weekend's radio and hearing the news that 'an expert panel has decided' that screening for prostate cancer should not be routine, and instead should be confined to 'high risk' portions of the population.
Which seems on the face of it... counter-intuitive. At a population level there's maths to suggest treatment perhaps should be applied more sparingly, but knowing the results of screening isn't on its own a bad thing, right? Or is this decision more about using over-stretched NHS resources more economically??
Absolute madness. I get tested every few years due to meds. Just got a friend diagnosed and it only happened because he was in hospital for sepsis = blood tests found his PSA was off the scale. It's the biggest cancer in blokes, so let's not test for it ? Madness
My sister has just been diagnosed with breast cancer. Her first mammogram at 52. Otherwise it may not have been found early enough.
The experts always insist that some men are treated un-necessarily and are "harmed" by their treatment. The treatment is quite brutal for all stages of this cancer... I believe that more men should be tested but not necessarily treated unless there is little doubt of the benefits.
I speak as a 56 year-old, who was diagnosed at 53 years old (PSA 374, spread to lymph nodes, stage 4 incurable) I had NO symptoms and was not at increased risk!
I have since met several men who share similar stories, although most are 20+ years older than me. My stupid* stepfather has just been diagnosed as stage 4 (spread to bones). He claims he had no symptoms until he couldn't pass urine one morning a few weeks ago. He's 80 years old; I would not have much treatment at his age but he wants the lot! (Hormone, chemo, etc.).
* Stupid man didn't get a PSA test despite seeing what I've gone through. This could likely have been fixed if he'd caught it earlier but now it's likely he'll have a miserable time of it.
TLDR... get tested; consider treatment.
Just catching up on the weekend's radio and hearing the news that 'an expert panel has decided' that screening for prostate cancer should not be routine, and instead should be confined to 'high risk' portions of the population.
Which seems on the face of it... counter-intuitive. At a population level there's maths to suggest treatment perhaps should be applied more sparingly, but knowing the results of screening isn't on its own a bad thing, right? Or is this decision more about using over-stretched NHS resources more economically??
Maybe we're lucky at my GP surgery, but as a white male >50yrs I can ask for a PSA test whenever I want one, but it's a test with limitations that can cause unnecessary harm.
If this is "normal" then it's a simple matter of personal choice. Why do we need a routine screening programme which entails unnecessary cost in administration and the necessary resources?
A mammogram does need specialist resources and is more suited to a national programme, IMHO.
Intuition says testing for all, but I read/listened to the argument against and I now I've been persuaded otherwise. Maybe I'm naive thinking that the experts know better than me, maybe it's all a conspiracy and just a way of reducing NHS costs.
They have standard but optional PSA tests here in Schweeden, starts at 50 and then every two years. You get a letter with a 6 week window to get the blood test done. (If you miss it you go to the back of the queue. And wait 2 years.)
If you hit their threshold you go into advanced screening, then *more* advanced. Depending on by how much you pass the threshold by.
I'm just passed the lowest threshold, so will get an MRI sometime around Xmas.
If you have symptoms, they do the test straight away.
Only about a third of men get in the system before they hit 60. (even if it's only one test out of the 6 they are entitled to)
Why do we need a routine screening programme which entails unnecessary cost in administration and the necessary resources?
Possibly because so many people are completely unaware of prostate cancer, the testing for it, or the importance of early detection. Maybe a campaign to promote awareness would be better? A letter to men >45 describing the risks and inviting them to make a personal decision to arrange a test if they wish?
Couple of reasons, both perfectly rational.
1) False positives. Quite high for this kind of screening, and will lead to lots of blokes suffering quite invasive biopsies unnecessarily.
2) The vast majority of prostate cancers are what is known as 'silent' - small, slow growing, with no potential to impact the health of the man during his natural lifespan. Something like 30% of 50-year-olds have some evidence of prostate cancer, and 80% of 80-year-olds. Distinguishing between the minority of aggressive versions which will spread and kill a man and those which will never affect them is quite hard.
Mass screening would catch more aggressive cancers early, and undoubtedly save some lives. But it would mean intervention in a lot of cases where it isn't needed, and the kind of treatments/surgical interventions we're talking about are far from trivial, and can have a devastating impact on quality of life for the patient. So you'd have lots of blokes wandering around with permanent erectile dysfunction or lack of sensation, or poor urinary control, or the side-effects of testosterone-reducing therapy, who simply never needed treatment.
Even if you screen, find a 'positive' but then decide the patient is not sufficiently high-risk enough to demand treatment, that can have a significant psychological impact on that person, being told 'you have cancer, but we're just going to wait and watch'.
In short, mass screening is a useful tool, but it can have real downsides as well as upsides. Those have to be balanced carefully to make sure you're not doing more harm than good.
Obviously there is a financial side to the equation (and people are right not to trust that decisions are not always made for purely clinical reasons). But mass screening programmes are expensive, and whenever you spend money somewhere, you stop it being potentially productive and life-changing somewhere else in the NHS.
Even the experts can't totally agree on this, I can see both sides of the argument. I think the decision made, even if some disagree with it, was made in good faith and was evidence based. Intuitively, without any knowledge it's easy to think "why wouldn't you screen"? but as articulated so very well by @martinhutch above, there are actually some good reasons why you might not want to.
However, nobody is diagnosed solely on the basis of a PSA test. A "high" PSA result alone does not necessarily mean cancer and will be followed up with more blood tests, an MRI and a biopsy if anything concerning is seen on the MRI. It is the combination of all those things (and potentially other tests) which inform a diagnosis.
This is all VERY topical for me. I was diagnosed 3 years ago with a low grade cancer and went on "active surveillance". I was without symptoms and was only diagnosed "accidentally" after a UTI, quickly sorted with antibiotics, because a follow-up PSA test was suggested. No one pushed me into treatment, I had an MRI and biopsy and was provided with the information and made my own informed decision not to have treatment at that stage.
Then this autumn a spike in PSA, followed by a new MRI and biopsy showed my cancer had increased in size and was now of a higher grade with a risk of spreading and treatment was strongly recommended. The surveillance did what it was designed to do. I have just had robot assisted radical prostatectomy (6 days ago).
I am reasonably confident, from everything I've been told that I have not had "unnecessary treatment". I am also reasonably confident that my treatment, although a bit brutal has a good chance of saving my life.
Whether there is a national screening programme or not, the key thing is to get checked if you have concerns. There is nothing to stop you asking your GP for a PSA test if you have symptoms, are of an age or in a higher risk group.
In the spirit of a PSA, it is good to know that PSA tests are available online for £45* (this is still for lab analysis to get an actual score, not just a binary high/low). Many GPs will refer for a free test but it is not always clear what the criteria are.
Having seen various outcomes from family members having prostate cancer identified at various levels of earliness, I plan to test regularly for the rest of my life.
On getting a high reading, it is useful to know whether PSA has been creeping up by 10% per year for a decade, or if this is a sudden spike after years of not much.
*I use medichecks, other providers probably exist. 25% off for black Friday! https://www.medichecks.com/products/psa-prostate-specific-antigen-blood-test
I think martinhutch has described the issue pretty well but just to add some anecdote - my FIL was diagnosed about 8 or 9 yrs ago with various options considered but a "wait and see" strategy being adopted. He goes twice a year to get his PSA checked, each time he spends a week or so worrying about the outcome. A few times he's been called back for more scans etc. He's has a very invasive biopsy. He has just had another MRI. He seems to be expecting a further biopsy. The last one took several weeks and few rounds of antibiotics to fully recover from - he's not 100% sure he wants to do it, but he feels his wife wants him to and his daughters expect him to "fight" any cancer - at nearly 80 he's not sure he wants major surgery or 100 mile round trips for radiotherapy etc. All the while it's "his" decisions not to have it whipped out so he spends his time worrying if he's made the right decision. He and his wife are retired on a comfortable pension and enjoy travelling but book their travel and plans around "what ifs" with his test results etc. He's not had a miserable time but anyone who is sitting there thinking "I'd rather know" perhaps hasn't really understood the pressures.Which seems on the face of it... counter-intuitive. At a population level there's maths to suggest treatment perhaps should be applied more sparingly, but knowing the results of screening isn't on its own a bad thing, right?
Well the reality of ANY healthcare system is that it has to use its finite resources to best effect. If you PSA screen everyone, there are fewer appointments for people with symptoms and other conditions, if every elevated PSA gets a referal to a consultant and MRI'd then those in the highest risk groups take longer to get seen and are fewer MRI appointments for people with other conditions too. Inevitably some of them then get biopsies - pushing up delays for others who may or may not be more clinically urgent, and some of them will opt for very invasive surgery with quite significant levels or side effect and high (20%?) levels of regret.Or is this decision more about using over-stretched NHS resources more economically??
None of that means that we shouldn't eventually screen people - but that first we need far more accurate screening tests, or other ways of filtering the people being screened so that the results are more likely to indicate a cause for concern - the problem is PSA is not black and white, 3/4 of people with an elevated PSA don't develop cancer in the following 10 yrs.
Mass screening would catch more aggressive cancers early, and undoubtedly save some lives.
Good post but on this point the evidence points otherwise: deaths from all causes are the same in screened and unscreened groups.
Many GPs will refer for a free test but it is not always clear what the criteria are.
The criteria are being male, aged over 50 and asking for one.
The best evidence we have does not support blanket screening which is why the leading charity Prostate Cancer UK aren't calling for this and neither are the National Screening Committee. I'll follow their advice before random anecdotes on this thread [whoops editing: just read poly's post above which conveys what Im trying to rather more effectively, but I'll leave this here anyway] They say if you're Black, know you're at elevated genetic risk, or get up frequently for a wee in the night then ask for one. I've had two. Will leave it a few years before I have another.
Thing is if you know you have a probably harmless cancer (which a high proportion of us will) lots of folks will want it chopped out, with risk of serious harm and probably no benefit, but will tell themselves thank goodness it was caught early (and the more harmed they are the more they'll tell themselves this, quite understandably).
Working "in the industry" so to speak unless there's some knew test we know nothing about then yes a screening of men would overwhelm the pathology service, not to mention those that go on to have needle cores taken (again pathology testing but much more labour intensive in every aspect. All for detecting anomalies that won't effect the majorities life expectancy but might reduce that life style with impotency and incontinence. Much better to better target those in the higher risk categories
plans around "what ifs" with his test results etc. He's not had a miserable time but anyone who is sitting there thinking "I'd rather know" perhaps hasn't really understood the pressures.
I'd agree with that. My 3 years on "active surveillance" were punctuated by constant low level anxiety which peaked at every 3 month blood test result. I also had a routine biopsy go badly which resulted in an unplanned hospital stay. I don't want to overplay it, life goes on in between, but it does have an impact.
Thanks some good posts. I asked NHS for PSA test doc but nothing happened. I pay privately and do every year so I can see any change. Private doc said if a spike happens, get a retest.
I ll re ask NHS doc for test, I was fobbed off last time.
Thanks for heads up re NHS test.
I got diagnosed positive last year at age 60, I’ve had BPH since 48 and been on active surveillance for the last 2 years. An MRI showed an anomaly, a biopsy result was positive with a the Gleason score of 6 (the lowest) and although I was offered radiotherapy and surgery, I declined. Since then I’ve changed my diet and my PSA has dropped a third and I’m now right on the threshold. Talking with the specialist it is fairly common for level 2 prostate cancer to not develop any further but I’ll continue to get regular PSA tests to make sure. There are other less-invasive treatments available but not on the NHS (yet) and might be available in the future. One issue is that for low grade cancers, the NHS treatment options are fairly major procedures not without side effects. From my POV, I would certainly encourage everyone to get tested as the signs of poor prostate health aren’t sometimes obvious. I also think that there’s not enough information on maintaining good prostate health as the effects of diet and reducing inflammation can have a significant impact.
What kind of dietary changes have you made? Just being nosey… it’s interesting. Humans now tend to live much longer than some of our organs, let’s face it. Many of us men will have prostate cancer by the time we’re finished. I’m with those that think we should have screening, but with a better understanding in society about what results do/don’t mean.
I also think that there’s not enough information on maintaining good prostate health as the effects of diet and reducing inflammation can have a significant impact.
Well I for one did not know that - so it could definitely do with better sharing of that information!
I’m with those that think we should have screening,
We would all like screening. The problem is that the PSA test is so inaccurate that blanket use would currently do more harm than good. (This situation may change - hence the PROTECT study, and regular review by the National Screening Committee.)
Diet-wise it has mainly down to eliminating refined sugars, processed foods, saturated fats and any additives and the main focus on fresh fruit and veg, pulses and whole grains, oily fish and lean meats. There are lower instances of prostate cancer in areas with a Mediterranean Diet - foods rich in lycopene such as red and pink fruit and veg plus olive oils aids absorption. As well as my blood PSA dropping, I’ve lost about 10kg but the weird thing is that it hasn’t really felt like a diet. My symptoms of frequency and urge to wee is considerably reduced - no longer having to get up at night. I’ll be interested in my next MRI result and whether my prostate has got smaller - it was previously the size of lemon vs regular walnut size.
Too late to edit. I meant the TRANSFORM trial: https://prostatecanceruk.org/research/transform-trial (Protect was the previous one).
Anti-inflammatory diet? This is definitely worth following; I think it's one of the things that is helping me keep well... and hopefully far outlive my prognosis 🙂
Inflammation within the body is now believed to be the cause of many illnesses. You probably know how to reduce it, as it's the same "healthy" advice that has been talked about for many conditions:
- Eat vegetables, nuts, wholegrains, healthy fats, beans, lentils, etc.
- Avoid processed, sugar, simple carbs., etc.
- Plenty of healthy proteins
- Avoid alcohol: drink green tea and the like
- Improve gut health (Kombucha, Kefir, etc)
- Exercise
- Prioritise a good night's sleep
- Supplements and spices (Curcumin, ginger, cinnamon)... maybe less evidence for this lot!
Regarding anxiety around PSA tests... I have mine every 3 months. It's been below 1.0 for some time now, although every new twinge or symptom and my mind still races... "It's spreading again!"
Edit... beaten by @dovebiker!
The problem is that the PSA test is so inaccurate that blanket use would currently do more harm than good.
Point of pedantry... it would seem that the follow up to the PSA test is so invasive and painful, and used relatively indiscriminately, that it does more harm than good. Knowing a PSA figure is higher than it was 6 months ago is not inherently a bad thing; it's the extent to which the next step is a biopsy etc etc that's more challenging
Point of pedantry...
It's the mouth of the funnel that draws in a lot of men who shouldn't be
GP here - PSA testing and prostate cancer are, as always, a very emotive subject.
I can FULLY understand why the general public would want many conditions screened for - in general the screening programme is amazing, and can detect and manage many significant illnesses. However, as things still stand, there's no PSA screening (remember, screening is performing a test in ASYMPTOMATIC individuals) as it doesn't meet screening criteria.
Here are the key criteria typically used in the UK (based on Wilson & Jungner principles, which still underpin modern screening guidance):
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The condition should be an important health problem with a significant burden in the population.
- hence we don't screen for athlete's foot!
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There should be a detectable early stage where intervention is more effective than waiting for symptoms.
- may well be the case with prostate cancer.
-
The natural history of the disease should be well understood, including progression from early to late stages.
- Here could be a challenge - take breast cancer; breast cancer = always bad. Same with bowel cancer =always bad. It's not always the case with prostate cancer, hence many people are on a 'watch and wait' approach.
-
The test should be simple, safe, reliable, and validated, with good sensitivity and specificity.
- PSA isn't.
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There must be an accepted, effective treatment for people identified through screening.
- This does apply to prostate cancer - chemo, radio, or surgery.
-
The screening programme should improve outcomes compared with usual clinical care (i.e., it must actually help).
- It doesn't with prostate cancer. Essentially, diagnosing more men with prostate cancer doesn't improve the health outcomes, at a population level.
-
The benefits should outweigh the harms, including overdiagnosis, anxiety, or unnecessary follow-up procedures.
- Again, not really the case with PSA testing.
-
The programme must be cost-effective for the NHS and feasible to deliver at scale.
- Unknown.
Only if these criteria are met, can a test be used for screening.
As an extreme example, I've actually pioneered a test that picks up 100% of prostate cancers, and could eradicate them all. The test is this : Do you have a prostate?
If you answer YES, then you have your prostate removed immediately.
Yes, this is in jest, but that test would be 100% sensitive (as in, it would miss ZERO prostate cancers), but not at all specific!
It's an interesting development in the testing and screening realm, and I'll certainly be watching this space.
DrP
Only point to add is on the subject of paying for your own online test.
It gives you a number, perhaps one you can take back to your NHS GP, but IMO an almost equally important part of PSA testing (and possibly oft-neglected) is the support, practical and emotional, that the patient gets to interpret the number, reassure them as required and not leave them feeling alone, uninformed and like the world is about to fall in.
Perhaps some of the private test providers offer this, I've never used one, but my guess would be that this is not top of their list of priorities.
Lol'ing at @DrP cracking the problem, and the walnut...
It's possible that prostate removal at age 40 would sort out a lot of problems by cutting global testosterone levels.
Martin, you might have got your nuts mixed up with regards Testosterone !
This is true. Unless you get TRT alongside whipping your prostate out, just to be on the safe side.