Posted on 05/29/2004 9:08:45 PM PDT by neverdem
FOUR nanograms of prostate specific antigen, or P.S.A., per milliliter. For more than a decade, that has been the line between normal and abnormal on a common annual blood test used to screen for prostate cancer. Above four and you need a biopsy of your prostate to look for cancer. Below four and you go home.
But a new study, published last week in The New England Journal of Medicine, showed that no matter how low his P.S.A. level, a man could have prostate cancer.
In addition, it has long been known that men whose prostates are enlarged, a normal consequence of aging, can also have P.S.A. levels indistinguishable from those with early prostate cancer.
So the question arises: How did four become the standard? Even some leading urologists say they aren't sure.
Dr. E. David Crawford, the head of urologic oncology at the University of Colorado Health Sciences Center, says a 1986 paper by a test maker, Hybritech (now part of Beckman Coulter), proposed that number as the divider between normal and abnormal P.S.A. levels.
But Dr. William Catalona, director of the prostate cancer program at Northwestern University, said he was primarily responsible for generating interest in using the P.S.A. as a screening tool, first advocating its use at a 1988 meeting of the National Cancer Institute.
The test finds a protein, the prostate specific antigen, that is released by prostate cells. Its levels go up slightly early in the course of cancer, but also when the prostate grows larger as a man ages. When cancer is advanced, P.S.A. levels soar into the thousands, but the test is looking at levels where only a biopsy could tell whether or not cancer was present.
Dr. Catalona knew that, but, he said, given the seriousness of the disease, "we were willing to pay that price."
Not everyone agreed. "I was howled down," at the cancer institute, he said. "They were looking for something like a pregnancy test; when it was positive you always had cancer and when it was negative you never did."
Unfazed, Dr. Catalona began his own P.S.A. study with the support of Hybritech, in which any test result over four nanograms was considered abnormal. But that cutoff, the same as in the Hybritech paper, was adopted "just sort of arbitrarily" he said.
The usual sort of study to validate a screening test would determine how likely the test is to miss a cancer that is there and how many times it points to cancer when none is present. But Dr. Catalona's test instead asked only how often cancers were found and how the men fared after treatment.
In 1991, his findings appeared in The New England Journal of Medicine. That, said Dr. Peter Albertsen, chief of urology at the University of Connecticut, convinced urologists. Four became the standard.
But some say it has resulted in way too much testing and way too many biopsies. Dr. H. Gilbert Welch, a professor of medicine at Darmouth College and at the Department of Veterans Affairs Medical Center in White River Junction, Vt., attributes the appeal of the number four to "digit preference." Doctors, he said, like whole numbers, they like clear results.
Unfortunately, he said, cancer, and prostate cancer in particular, is not like that. "If the P.S.A. gets very high, it is telling us something," he said. But lower levels, certainly levels below 10, lead to the discovery of microscopic cancers that no one understands. Most are harmless and will never grow. Some are dangerous, but there is no way of distinguishing between the two. "We just don't know what it means," Dr. Welch said.
Prostate cancer is so common that virtually every man gets it if he lives long enough, said Dr. Thomas A. Stamey, a professor of urology at Stanford. Yet only rarely is it life-threatening. Screening, Dr. Stamey said, fueled by a false sense of confidence in what is normal and what is not, has led to far too many biopsies, far too many discoveries of cancers that pose no danger, far too many prostates removed or destroyed.
Dr. Catalona is of the opposite camp. He says he has moved his cutoff down a notch, to 2.5. He has seen too many men, he says, who ended up with deadly cancers because they waited for their P.S.A. levels to creep above four before having a biopsy.
But Dr. Stamey said, "I have some smart colleagues who are very proud of the fact that they used to stand up at meetings and say, 'I never had a P.S.A. test in my life, and I don't plan to have one.' " Given the new study, he said, "it looks like they were very insightful."
bump
trust me - in 10 years all the current dogma about cholesterol will be debunked as well.
I wonder if Rudy Guliani had symptoms or just an elevated PSA to enable him to bow out against Hillary. IIRC, his father had prostate cancer, but did he die from it?
I don't see Rudy as a Senator, as much as other pubbies want him to run for the Senate. I believe he wants to succeed Pataki. I don't ever expect to be seeing Rudy on a national ticket. He's way too liberal.
I would have not voted for Rudy anyway. Too too liberal and flaunting his little hussy while he was married didn't sit well with me.
The choice of words here makes me a bit squeamish, when discussing this part of the anatomy.
I've been typing urology reports for 8 years. if they feel something out of sorts, they get a biopsy with a less than 1ng psa. if i am remembering right, cancer with a very low psa can be the most fatal. and young guys in their 40s can get it.
i'll be interested to what the urologists have to say, but my guess is that the psa is a very useful tool, and the PSAII is an even more useful tool. you guys get those psa tests done!!!
That's what I tell my male clients all the time and I'm not even a doctor. Get the test done. Also, a testicular exam too... a minute and it's over.
Some of it already has been. Butter, for example, is no longer being classed as a deadly poison.
If you have a high PSA, the next step is an ultrasound to look for nodules, and a biopsy of the nodules. If there are no nodules, then they do six "blind" biopsies. You don't get a diagnosis unless one of the nodules is cancerous
There is a BIG controversy about the PSA test. You see, most prostate cancers grow slowly and you die of old age before it kills you. But some grow quickly. And it's impossible to tell by biopsy which cancer it is.
at the last conference I went to, they estimated if you find five cancers, three would grow slow and not kill the patient, so it would make no difference if you treated it or not. One would grow so fast that treatment would make no difference. And one person's life would be saved by treatment.
The treatment has a side effect of exhaustion. The radiation makes one tired, and the "anti hormone" shot causes depression. The anti hormone shot is used in lower doses to treat endometriosis, and I took it for three months and cried all the time. So I warn my men that they will become depressed, and advise them to stick it out and offer them prozac...
Guliani quit the Senate race when he realized that he was too tired to run the city and run for the Senate. That suggests full treatment for an aggressive cancer. Since Kerry didn't do this, it makes one suspect either he had opted the surgical treatment (poor Teresa, since surgery causes impotence) rather than the radiation/chemo approach (Gulliani is now on his third wife, and she seems happy)
But a new study, published last week in The New England Journal of Medicine, showed that no matter how low his P.S.A. level, a man could have prostate cancer.
Can't anyone read OR think anymore?
The two statements above are not contradictory.
#1 describes who should have biopsies.
#2 says anyone can have cancer.
Both of these statements are true, and #2 does not contradict #1.
It is surprisingly common how many patients ask to be guaranteed 100% that they don't have cancer.
Since most cancers are in the pre-diagnosable phase at any given time, this is an impossible mission.
If every man had a prostate biopsy every day, we would find more cancers.
So what?
well, for cases under 4, you go by the art of medicine.
If they have a nodule, you refer. I had one patient whose PSA went from 2 to 4 in 18 months. He had cancer.
But very high prostate tests may mean infection, not cancer. So you repeat them.
I've had one man with a PSA of 15 that went back to normal: Acute prostatitis
But it can still fool you. I had another whose PSA jumped to 8 after open heart surgery. We watched it because we assumed it was from the urinary catheter during surgery causing infection, but the PSA kept going up, so we referred, and found it was widespread cancer, not infection...and ironically, he died of other causes two years after we diagnosed him...
Gina Kolata has been printing "Doctors think they are God, but they really aren't" articles for thirty-two years.
I sat in on a lecture by a doctor from the local university. He stated that a lot of medical practice is based on tradition unproven by study. Cholesterol as an example has never been proven to be linked to heart disease.
"trust me - in 10 years all the current dogma about cholesterol will be debunked as well"
Yup. I agree 100% with you.
I appreciate your refresher on prostate CA, but I remain convinced that being a senator was something Guliani never aspired to, let alone suffer another election loss.
Guliani lost his first election for Mayor to David Dinkins who was black in 1989. When he ran again and won against Dinkins four years later, who presided as mayor during a time of the worst crime rates, over 2,100 - 2,200 murders per year and race riots in Brooklyn, the Black leadership of the city never forgave him. They bedeviled him like harpies for eight years.
He won in a city in which the rats have at least a 5 to 1 advantage in registered voters over the pubbies. Statewide, the rats have 5 million registered voters compared to 3 million pubbies. There are about 300,000 registered Conservatives who could give a rat's @ss about Guliani, who witnessed Al D'Amato's loss to Schumer in 1998 by a 10 - 11% margin. That margin of victory was about the same as Hillary's in 2000 over Rick Lazio(sp?). While Guliani has endorsed so many liberal issues, he's no fool.
I think a lot of this testing they do for cholesterol is market driven by instrument companies who want to sell their tests. They're just responding to the latest health hysteria.
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