The PSA test is used to help to determine if a man has prostatic cancer or not. If the PSA is high and/or rising, then doctors have argued to me that this signifies a higher risk of cancer.
Like many men in their sixties, I was advised by my GP to have a PSA test. He is a good bloke and I complied. It was “high”. I was referred to a urologist who recommended a biopsy which would give a better indication if cancer were present or not.
So I asked, given the level of my PSA, what the probability was that I had cancer; if I had, what the probability of death was without treatment and what it was with treatment. He responded: “I don’t deal in probabilities!” I then asked (he thought rhetorically!): “How can I make an informed decision?”
I gave up.
Then about a year later, I stupidly had another PSA test. It was “high” so I saw another urologist … it was again suggested I have a biopsy. I had one and I was clear.
Then when recently I asked my GP for an overall health check (as I want to run a marathon this year), he included a PSA test. It was “high” — everything else was fine. So back to see the second urologist again. Advice? Have a biopsy.
Again my response: what are the probabilities? Doesn’t know but in my presence rings a urologist colleague “who is one of these chaps who has all the numbers”. Explains over the phone “I have this patient who is a scientist like us and wants to know the stats.”
But that urologist was going on holiday for four weeks…
So what do I do?
I have been to the Cochrane website (screening for prostate cancer), the cathedral of evidence based medicine. It states on PSA testing:
Given that only two randomised controlled trials [have been conducted], and the high risk of bias of both trials, there is insufficient evidence to either support or refute the routine use of mass, selective or opportunistic screening compared to no screening for reducing prostate cancer mortality.
So maybe I didn’t get the probabilities because they don’t exist?
The Cancer Council Australia states:
Men at above-average risk of prostate cancer should … be given adequate objective information about the potential benefits and harms of screening, diagnostic procedures and treatment for prostate cancer to allow them to make a fully informed decision on whether to be tested or not.
So why do I and I presume so many other men have such difficulties in getting “adequate objective information”?
Being told that the results of a test suggest a higher chance of cancer does stimulate anxiety in the man concerned and in his nearest and dearest. I know. More PSA tests and biopsies also mean more fees for doctors. In a health service strapped for cash, do we really need so many of these PSA — Potentially Stimulating Anxiety — tests?
And as a footnote: having coffee with a colleague of my same age group last week, I mentioned all of this to him. His response? “I would never think to question my doctor. I would just trust him and have the biopsy.”
But can we trust our fee-for-service doctors to do the right thing — and not more — when there is a fee attached?
I’m pleased for Gavin that his biopsies keep coming back clear despite high PSA readings.
Unfortunately, a few years after two TURPs, my father had a PSA of 19, and a Gleason of 7. Being over 70 and the cancer having spread outside the prostate capsule, his urologist wouldn’t operate. Radiotherapy and 2 years of hormone therapy followed. Cured or controlled? I don’t know.
I still hold his GP and urologist responsible – neither did a PSA test in the few years between his last TURP and cancer diagnosis, while the level was clearly rising. In my father’s case, the PSA test was the first sign of something that had been wrong for some time.
Some ‘red book’ that GPs use doesn’t even recommend PSA tests be administered – GPs are to wait for patients to bring it up. At least the version I found online. Nice. I love having to do everything myself – like Gavin, having to work out the risks, gather the data, request what treatment I think I need.
And doctors wonder why patients (and in my case, their worried and cranky children who accompany them to appointments) question them, seek second opinions and go their own way.
It is refreshing to read an article from a patient questioning the value of PSA tests for screening of prostate cancer, something that is an ongoing debate amongst doctors. However I do disagree with the implication (that doctors are mainly ordering the tests to earn more income) in Professor Mooney’s final rhetorical question ‘Can we trust our fee-for-service doctors to do the right thing…..when there is a fee attached?”
As a GP I frequently get requests for a PSA test as part of a routine health check. Patients often look taken aback when I ask them about symptoms and proceed to discuss issues such as probabilities and the risks and benefits of screening. After five minutes extra consult time (with no extra fee) they usually want the test anyway.
As with other GPs the cost of a PSA test is a deterrant rather than an encouragement for me to order it. I receive no extra income (above the routine consult fee) for ordering the test but I am well aware that there is a cost to myself as a tax payer, through the cost of the pathology to medicare. However this cost is not enough to help me swim against the tide of society and patient expectation.
Perhaps less PSA tests and biopsies will be done when doctors have less fear of being sued for missing the improbable.
If a Health Economist can’t get accurate, unbiased information what hope for the punters. Disregarding the PSA issue, having a biopsy is no picnic. There is a risk in having a biopsy and a percentage of men require the urgent attention of a vascular surgeon when ‘things go wrong’…but just try and get figures on that one..everyone runs for cover. And then if the biopsy shows you have prostate cancer…what type of treatment do you have? A radical prostatectomy(surgery), low or high dose brachytherapy(radioactive seeds), radiotherapy or hormonal therapy? Or do you opt for ‘watchful waiting’? Where you end up will depend on which urologist you have been referred to; only a handful offer brachytherapy and not all choose to recommend a consultation with a radiotherapist who treats a significant number of men with prostate cancer. Volume as with the treatment of most cancers is important in terms of acquired skills and good outcomes. But how do you find out that sort of information? Most GPs don’t have it and Cancer Helplines are not permitted to specifically recommend particular specialists. So – most men end up relying on the urologist to whom they have been referred and, if they are really lucky, that urologist will explain all the options. But don’t bet on it. And make sure that the next time your GP takes some blood that he/she confirms exactly what tests he/she is requesting. PSA tests are not recognised as an effective screening procedure. They may be in the future. Meanwhile, trust another older acronym: the ‘DRG’ – Digital Rectal Examination.
PSA concentration can rise dramatically with sexual activity. The test should not be taken within at least two weeks of complete celibacy.
Very few doctors even know this, leave alone tell their patients to desist from any amorous or sexually arousing pursuits before having the blood sample taken.
My 65 yro prostate (gleason score 7) was removed in August, some 3 months after twice getting a higher PSA reading. My regret is about not insisting on a quicker biopsy — of accepting the initial complacency of ‘probably no need to worry’.
I felt the internet coupled with the medical diagnosis gave enough information for me to confidently proceed to ‘get it out’ with little further delay.
The surgery (at the Mater) went well: I recovered very quickly and I have no residual problems — bar the worry of a recurrence, and the need to proceed to radiotherapy.
In short, if you are over 60 have a PSA test twice a year and respond immediately to any increase — and waste no time getting the biopsy.
Depending on that outcome the next steps are clear enough.