Can you please explain the rule-of-thumb that you've been using for 20 years. (Take your age. Divide your PSA by 10. If your PSA is higher than that, it likely warrants evaluation.)
I'm unclear about the parameters and the calculations. Let's take a specific example from my own record when I was 65, and my PSA was 10.47.
So I divide my PSA by 10 to give 1.047. You say "if your PSA is higher than that". What specifically is "that"? I'm completely confused! Shouldn't I be multiplying my PSA by 10, or dividing my age by 10?
That said, I totally agree with your views on PSA monitoring. I was stunned on hearing Biden's diagnosis, a condition that could have been so easily avoided if he'd undergone regular PSA testing,
Wow - my worst pushed typo in history of this site (that I'm aware of) - thanks for pointing out in a direct fashion. Age/10 > PSA. In your example 10.47>6.5 - need to do more stuff.
Thanks again for reading and giving a comment. Just a typo - it is corrected thanks to this comment.
OK, that makes sense. Thanks for clarifying. To complete my story, I had been doing a lot more than just PSA tests, in line with your rule-of-thumb. When at age 72 PSA exceeded my age/10 by a factor of 2.7, I got radiation treatment with ADT, which seems to have fixed the problem.
In the ProScreen trial only 2.7% of the men screened with a PSA had a biopsy!JAMA Net 4/6/24 (positive 4K and mpMRI)
Of 15 201 eligible males invited to undergo screening, 7744 (51%) participated. Among them, 32 low-grade prostate cancers (cumulative incidence, 0.41%) and 128 high-grade prostate cancers (cumulative incidence, 1.65%) were detected, with 1 cancer grade group result missing. Among the 7457 invited men (49%) who refused participation, 7 low-grade prostate cancers (cumulative incidence, 0.1%) and 44 high-grade prostate cancers (cumulative incidence, 0.6%) were detected, with 7 cancer grade groups missing. For the entire invited screening group, 39 low-grade prostate cancers (cumulative incidence, 0.26%) and 172 high-grade prostate cancers (cumulative incidence, 1.13%) were detected. During a median follow-up of 3.2 years, in the group not invited to undergo screening, 65 low-grade prostate cancers (cumulative incidence, 0.14%) and 282 high-grade prostate cancers (cumulative incidence, 0.62%) were detected. The risk difference for the entire group randomized to the screening invitation vs the control group was 0.11% (95% CI, 0.03%-0.20%) for low-grade and 0.51% (95% CI, 0.33%-0.70%) for high-grade cancer.
Not only that but microUS is a much cheaper screening tool than an mpMRI. It is proving to be just as effective.
I believe men should be screened with a PSA, DRE, biomarker blood or urine test and a mpMRI or microUS. I would even negotiate skipping the DRE if that is the deciding factor against screening. I would also screen any age as long as they are healthy.
It's a nuanced space with tons of data. Reading this, I can't tell which side you land on? I obviously opted to focus more on clear large population trends than any trial. Thanks for reading and providing another good reference point.
As a PCP, let me try to address some of the points made in this article.
First, I completely agree that the vast majority of harm is due to "doing too much" instead of the "wait and watch" approach.
The problem with measuring prostate cancer-specific mortality is that it fails to capture all the harm and deaths from treatment. I made a short substack post on this problem in the context of colon cancer screening (https://substack.com/@sudeepbansal/note/c-114179247)
According to the study cited, prostate cancer-specific mortality increased after the Grade D recommendation. However, 2 other reasons could also lead to this outcome:
- If we remove a lot of prostates (including unnecessary ones), there will be fewer prostate cancers
- Shifting "deaths" from one bucket to another. Some people now dying from prostate cancer, would have died from complications from treatment that would not be attributed to prostate cancer. E.g. Surgical complications from prostatectomy, infections related to radiation proctitis, etc.
To put a square peg in a round hole--the performance of a screening test depends on the population characteristics and the culture of that population. We have a very risk-averse, anxious, over-advertised too, and litigious population.
Given the low, to minimal benefit/risk ratio and the constraints that we practice in, PSA screening will lead to more harm than benefit when implemented population-wide.
Can you please explain the rule-of-thumb that you've been using for 20 years. (Take your age. Divide your PSA by 10. If your PSA is higher than that, it likely warrants evaluation.)
I'm unclear about the parameters and the calculations. Let's take a specific example from my own record when I was 65, and my PSA was 10.47.
So I divide my PSA by 10 to give 1.047. You say "if your PSA is higher than that". What specifically is "that"? I'm completely confused! Shouldn't I be multiplying my PSA by 10, or dividing my age by 10?
That said, I totally agree with your views on PSA monitoring. I was stunned on hearing Biden's diagnosis, a condition that could have been so easily avoided if he'd undergone regular PSA testing,
Wow - my worst pushed typo in history of this site (that I'm aware of) - thanks for pointing out in a direct fashion. Age/10 > PSA. In your example 10.47>6.5 - need to do more stuff.
Thanks again for reading and giving a comment. Just a typo - it is corrected thanks to this comment.
OK, that makes sense. Thanks for clarifying. To complete my story, I had been doing a lot more than just PSA tests, in line with your rule-of-thumb. When at age 72 PSA exceeded my age/10 by a factor of 2.7, I got radiation treatment with ADT, which seems to have fixed the problem.
In the ProScreen trial only 2.7% of the men screened with a PSA had a biopsy!JAMA Net 4/6/24 (positive 4K and mpMRI)
Of 15 201 eligible males invited to undergo screening, 7744 (51%) participated. Among them, 32 low-grade prostate cancers (cumulative incidence, 0.41%) and 128 high-grade prostate cancers (cumulative incidence, 1.65%) were detected, with 1 cancer grade group result missing. Among the 7457 invited men (49%) who refused participation, 7 low-grade prostate cancers (cumulative incidence, 0.1%) and 44 high-grade prostate cancers (cumulative incidence, 0.6%) were detected, with 7 cancer grade groups missing. For the entire invited screening group, 39 low-grade prostate cancers (cumulative incidence, 0.26%) and 172 high-grade prostate cancers (cumulative incidence, 1.13%) were detected. During a median follow-up of 3.2 years, in the group not invited to undergo screening, 65 low-grade prostate cancers (cumulative incidence, 0.14%) and 282 high-grade prostate cancers (cumulative incidence, 0.62%) were detected. The risk difference for the entire group randomized to the screening invitation vs the control group was 0.11% (95% CI, 0.03%-0.20%) for low-grade and 0.51% (95% CI, 0.33%-0.70%) for high-grade cancer.
Not only that but microUS is a much cheaper screening tool than an mpMRI. It is proving to be just as effective.
Based on this trial very few men would be placed on active surveillance because we would only be detecting clinically significant cancers
I believe men should be screened with a PSA, DRE, biomarker blood or urine test and a mpMRI or microUS. I would even negotiate skipping the DRE if that is the deciding factor against screening. I would also screen any age as long as they are healthy.
I agree - we have too many tools and too much to loose. Just didn't want to assume - thanks for reading.
It's a nuanced space with tons of data. Reading this, I can't tell which side you land on? I obviously opted to focus more on clear large population trends than any trial. Thanks for reading and providing another good reference point.
This article is a good rebuttal to my rebuttal (https://www.pcplens.com/p/biden-and-prostate-cancer-screening) of Peter Attia's video (https://youtu.be/hnamfo1AzWc) on Prostate Cancer Screening.
As a PCP, let me try to address some of the points made in this article.
First, I completely agree that the vast majority of harm is due to "doing too much" instead of the "wait and watch" approach.
The problem with measuring prostate cancer-specific mortality is that it fails to capture all the harm and deaths from treatment. I made a short substack post on this problem in the context of colon cancer screening (https://substack.com/@sudeepbansal/note/c-114179247)
According to the study cited, prostate cancer-specific mortality increased after the Grade D recommendation. However, 2 other reasons could also lead to this outcome:
- If we remove a lot of prostates (including unnecessary ones), there will be fewer prostate cancers
- Shifting "deaths" from one bucket to another. Some people now dying from prostate cancer, would have died from complications from treatment that would not be attributed to prostate cancer. E.g. Surgical complications from prostatectomy, infections related to radiation proctitis, etc.
To put a square peg in a round hole--the performance of a screening test depends on the population characteristics and the culture of that population. We have a very risk-averse, anxious, over-advertised too, and litigious population.
Given the low, to minimal benefit/risk ratio and the constraints that we practice in, PSA screening will lead to more harm than benefit when implemented population-wide.