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Medical Forum / Diseases and Disorders / Prostate Cancer / July 2009More reading on PSA testing and levels
Interesting article on PSA testing and PSA numbers..... I call it PSA anxiety.....they should have a drug for it. john The Downside of Ultra- Sensitive Tests You've had the radical prostatectomy, but deep down, you're terrified that it didn't work. So here you are, a grown man, living in fear of a simple blood test, scared to death that the PSA- an enzyme made only by prostate cells, but all of your prostate cells are supposed to be gone -- will come back. Six months ago, the number was 0.01. This time, it was 0.02. You have PSA anxiety. You are not alone. This is the bane of the hypersensitive PSA test: Sometimes, there is such a thing as too much information. Daniel W Chan, Ph.D., is professor of pathology, oncology, urology and radiology, and Director of Clinical Chemistry at Hopkins. He is also an internationally recognized authority on biochemical tumor markers such as PSA, and on immunoassay tests such as the PSA test. This is some of what he has to say on the subject of PSA anxiety: The only thing that really matters, he says, is: ''At what PSA levels does the concentration indicate that the patient has had a recurrence of cancer?'' For Chan, and the scientists and physicians at Hopkins, the number to take seriously is 0.2 nanograms/milliliter. ''That's something we call biochemical recurrence. But even this doesn't mean that a man has symptoms yet. People need to understand that it might take months or even years before there is any clinical physical evidence.'' On a technical level, in the laboratory, Chan trusts the sensitivity of assays down to 0. 1, or slightly less than that. ''You cannot reliably detect such a small amount as 0.01,'' he explains. ''From day to day, the results could vary -- it could be 0.03, or maybe even 0.05'' -- and these ''analytical'' variations may not mean a thing. ''It's important that we don't assume anything or take action on a very low level of PSA. In routine practice, because of these analytical variations from day to day, if it's less than 0. 1, we assume it's the same as nondetectable, or zero.'' FURTHER READING Pound, CP; Partin, AW; Einsenberger, MA; Chan, DW; Pearson, JD; and Walsh,PC. ''New Method to Assess Risk of Advanced Cancer After Prostate Removal,'' Journal of the American Medical Association, Vol.281, pp.1591-1597. On July 26, John wrote: > Interesting article on PSA testing and PSA numbers..... > > I call it PSA anxiety.....they should have a drug for it. "PSA anxiety" is a waste of energy. Here's a very brief explanation of the utility of the ultrasensitive PSA test, from med onc and PSA specialist Stephen B. Strum, MD, who is far from alone: "The hypersensitive or ultrasensitive PSA is an inexpensive way to indicate the sensitivity of the tumor cell population to treatment with ADT and to establish an earlier diagnosis of AIPC if a PSA nadir of <0.05 ng/ml is not achieved and maintained." See, http://www.prostate-cancer.org/education/andind/Strum_ListeningToBiology.html And, "Following primary treatment, the use of more accurate tests such as hypersensitive PSA or ultra-sensitive PSA *can detect a recurrence 1-2 years earlier than the standard PSA which is accurate to 0.1 ng/ml*. (emphasis mine) From PCRI Insights, January 200,1 vol. 4, no. 1, page 11. And there is much, much, more on that site. I simply cannot understand why some men fear knowing the details of what is happening with their illness. I see nothing to be nervous about, except *not* knowing. > On a technical level, in the laboratory, Chan trusts the > sensitivity of assays down to 0. 1, or slightly less than that. ''You cannot [quoted text clipped - 4 lines] > routine practice, because of these analytical variations from day to day, if > it's less than 0. 1, we assume it's the same as nondetectable, or zero.'' Dr. Chan would get a lot of argument about that, but we should understand that in medicine as in many other fields of endeavor, hardly anyone agrees with anyone else. From this amateur's viewpoint, that last assumption is nothing short of dangerous. > FURTHER READING > > Pound, CP; Partin, AW; Einsenberger, MA; Chan, DW; Pearson, JD; and > Walsh,PC. ''New Method to Assess Risk of Advanced Cancer After Prostate > Removal,'' Journal of the American Medical Association, Vol.281, > pp.1591-1597. After a bit of searching, I found the above article at http://jama.ama-assn.org/cgi/content/abstract/281/17/1591 It was published in the May 5, 1999 issue of JAMA. Here is a relevant quote from the abstract: "Patients: A total of 1997 men undergoing radical prostatectomy, by a single surgeon, for clinically localized prostate cancer. None received neoadjuvant therapy, and none had received adjuvant hormonal therapy prior to documented distant metastases. Main Outcome Measures: After surgery, men were followed up with PSA assays and digital rectal examinations every 3 months for the first year, semiannually for the second year, and annually thereafter. A detectable serum PSA level of at least 0.2 ng/mL was evidence of biochemical recurrence. Distant metastases were diagnosed by radionuclide bone scan, chest radiograph, or other body imaging, which was performed at the time of biochemical recurrence and annually thereafter." ******** "Conclusions: Several clinical parameters help predict the outcomes of men with PSA elevation after radical prostatectomy. These data may be useful in the design of clinical trials, the identification of men for enrollment into experimental protocols, and counseling men regarding the timing of administration of adjuvant therapies." Old news, though interesting. Regards, Steve J I realize that it may be a "waste of energy" but I have to tell you that the anticipation and consternation over decimals can be unnerving. I have been at this for over 10 years now, and am pretty good at dealing with the + and - of Prostate Cancer and its side effects. I have not been spared many in the past. All in all my records have been very good, and any misunderstanding, or PSA value that comes with questions does raise my feathers...... I am a fighter, a survivor, and will be dammed if I let it beat me. john thanks for your input. I read all, and respond to many. > On July 26, John wrote: > [quoted text clipped - 84 lines] > > Steve J > I realize that it may be a "waste of energy" but I have to tell you that the > anticipation and consternation over decimals can be unnerving. If I found it unnerving, I'd stop getting ultrasensitive PSA readings because it would be doing more harm than good. 0.002, 0.030, 0.020 ... it's virtually random noise as a measure of post-RRP cancer recurrence. When it nears 0.100 I'll get concerned about it; I may even act if it hits 0.200, depending on what options are available by that time. I.P. On July 26, John replied to me, in pertinent part: > I realize that it may be a "waste of energy" but I have to tell you that the > anticipation and consternation over decimals can be unnerving. > I have been at this for over 10 years now, and am pretty good at dealing > with the + and - of Prostate Cancer and its side effects. I have not been > spared many in the past. Neither have I. As I posted elsethread, it is better to know than to be ignorant (quoting H. L. Mencken). But more importantly, here's something by some of the referenced "best and brightest" that demonstrates the clinical good judgment of the US test: Scholz M, et al., "Prostate-cancer-specific survival and clinical progression-free survival in men with prostate cancer treated intermittently with testosterone-inactivating pharmaceuticals." Urology, 2007 Sep;70(3):506-10: One result: "Death from prostate cancer was far more common (78% versus 11%) and accelerated (median of 4 years versus 7 years) for men with a PSA nadir greater than 0.05 ng/mL than for those with a lower nadir." (NB: *Nadir*) "CONCLUSIONS: Of the factors studied, the PSA nadir while taking a TIP was the best predictor of prostate cancer-specific mortality." When I said that the advice of such folks was good enough for me, this is one of the factors I had in mind. We DO NOT KNOW our PSA nadir when we cut off testing at an arbitrary point that has little to do with our clinical status. (Free opinion from an amateur) Please note: My remarks are not intended to be critical of John. It's just that I see this sort of thing frequently, and never yet have I seen a medically-valid reason for deliberately declining to know all possible about our disease. Regards, Steve J Tho' much is taken, much abides; and tho' We are not now that strength which in old days Moved earth and heaven, that which we are, we are -- One equal temper of heroic hearts, Made weak by time and fate, but strong in will To strive, to seek, to find, and not to yield. -- From "Ulysses" Alfred, Lord Tennyson I just wrote: > On July 26, John replied to me, in pertinent part: Et cetera. Rats. I neglected to cite the PubMed page for the Scholz article. The PubMed ID number is 17905106 Search on that number at the home page: www.pubmed.gov Pub Med is a service of the US National Library of Medicine. Regards, Steve J Red-faced. >And, "Following primary treatment, the use of more accurate tests such >as hypersensitive PSA or ultra-sensitive PSA *can detect a recurrence >1-2 years earlier than the standard PSA which is accurate to 0.1 ng/ml*. >(emphasis mine) I've no doubt this is true, but if there's no intention to act before 0.2 what purpose does this serve other than to provide 2 years of dismal certainty about the future? If we had the science using a simple test to predict, with precision, when we were going to die, how many of us would use it? I could see this being useful perhaps in later years so as to close one's affairs smoothly, but my guess is that up to middle age (40-60 years) most would be happier being totally ignorant of the date their death. > >And, "Following primary treatment, the use of more accurate tests such > >as hypersensitive PSA or ultra-sensitive PSA *can detect a recurrence [quoted text clipped - 10 lines] > smoothly, but my guess is that up to middle age (40-60 years) most > would be happier being totally ignorant of the date their death. One also has to ask, what is the purpose of interviening at an earliar date. Does one expect a cure and if not then why subject yourself to a the side effects of hormone therapy any sooner than necessary. I've seen some use the phrase,"Nip it in the Bud" and others state, " In Hopes for a Cure". I don't believe they have found a cure as of yet but I could be mistaken if someone would inlighten me I would appreciate it. Ron S. On July 27, Ron S wrote, in pertinent part: (snip) > One also has to ask, what is the purpose of interviening at an earliar date. (snip) Please note that those I cited did not say that the purpose of the US test is to intervene. Though I think that it certainly can give us the opportunity to do so if we choose. My purpose in having US tests every 28 days is to keep a very close eye on what is happening. I must do so because of my high-risk case. Others likely have other reasons. And the best and brightest recommend the US test, as briefly cited above. That's good enough for me. My med onc quite correctly told me that I "don't do well, not knowing." It's a matter of personal inclination, backed by sound medical advice. YMMV and does. Regards, Steve J "As a physician, I am painfully aware that most of the decisions we make with regard to prostate cancer are made with inadequate data." -- Charles L. "Snuffy" Myers, MD Medical oncologist. PCa survivor. >One also has to ask, what is the purpose of interviening at an earliar >date. Does one expect a cure and if not then why subject yourself to a [quoted text clipped - 5 lines] > >Ron S. That's how I feel about it now. I'm even veering towards a possibly more reckless approach borne of a sense of optimism (perhaps unwarranted!) that as time goes on, the trajectory or our disease progression has an ever increasing probability of intersecting with a range of better treatments. Coming back to John's anxiety, I should have said that even the crude <0.1 jobby does nothing for my peace of mind - I still get an attack of the willies while waiting for the results but at least I'm not fretting about a range of results that are absolutely irrelevant to my strategy. Lucky for those who don't worry but for those who do, even if worrying is an irrational process, there are rational ways of softening its blow. : On July 26, John wrote: : I simply cannot understand why some men fear knowing the details of what : is happening with their illness. I see nothing to be nervous about, : except *not* knowing. Perhaps that is because you have not been in that position. One who has been T1 or T2 and is undetectable cannot help but to be concerned by a detectable (by some standards) result. We feel like we beat it and suddenly there is a blip in a test that is very often correct in indicating the bastard was not delivered the death knell we hoped for it. I experienced it in December 2001 when my string of <0.10 was broken by a 0.27. It was not treated until May 2002. Looking backwards, I might have been a 0.05 about June 2001. I appreciate the fact that I did not know it then. Whether or not I would have "wasted my energy" with trepidation is not really an issue considering we have seen many anxious brothers here and reports by physicians whose statements have been posted here say that it is common. That pretty much makes the understanding of the condition moot. That said, some of us, including you and me, no longer have the benefit of thinking we are cured. I know for a fact that one day, my <0.05 is going to be a 0.05 or worse. I'm a T3 and those are just the facts of life. For me, it is a matter of when, not if. I honestly don't care if I get standard testing or sensitive testing. As a matter of fact, I am disappointed when I see the <0.10. But, my circumstances of changed.  SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA <.1 <.1 <.1 .27 .37 .75 PSAD 0.19 years EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 PSAD .056 years Lupron 07/03 (1 mo) 8/03 and every 4 months there after PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years Casodex added daily 07/06 PSA undetectable since; last checked on 06/04/09 Illegitimati non carborundum > One who has > been T1 or T2 and is undetectable cannot help but to be concerned by a > detectable (by some standards) result. Men who feel that way probably shouldn't get ultrasensitive tests. The rest of us are happy our glass is only -- or less than -- half full @ 0.050. My string of 0.0xx's is reassuring, not alarming, as it continues to tell me I'm still dodging the beast and may continue to do so until better secondary treatments are available. I.P. >Interesting article on PSA testing and PSA numbers..... > [quoted text clipped - 39 lines] >Removal,'' Journal of the American Medical Association, Vol.281, >pp.1591-1597. I'm perfectly happy with the crude '<0.1' test I've been getting these last 2.8 years. Recurrence is something I'm expecting sooner or later so I'm happy to have been living my life, so far, in a state of contented denial. I know I'm not cured but I'm not preoccupied either (aside from the occasional visits here, that is). There'll be a wide enough window of opportunity to cope with the brutal truth when it's staring me in the face. As with the primary treatment, I remain unconvinced that whatever action needs to be taken should happen with prompt urgency. |
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