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Comment by scandox | Hacker News Reader

This makes me think of an article I read about prostate cancer detection. Apparently, it is possible to detect the possibility of prostate cancer many, many years before it is going to develop with a more sensitive, modern test. Once the detection is made both patient and doctor are not in a position to ignore it. At the same time treatment may well be premature or not recommended. But the doctor is left with a dilemma because it may appear they did not take action on something they knew.

That at least was the general topic of the article. The question it raises is interesting: is it sometimes too early to know.

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> Apparently, it is possible to detect the possibility of prostate cancer many, many years before it is going to develop with a more sensitive, modern test. Once the detection is made both patient and doctor are not in a position to ignore it.

I'll tell you a story from when my mother was in medical school.

There was a class one day in which the students were given a pile of slides of prostate samples and told to identify the cancerous one. Many, many questions ensued, of the form "This looks kind of cancerous. Is this the slide?"

Eventually the professor announced to the class "look, there's a bit of cancer in everyone's prostate. The goal here is to find the slide with OBVIOUS cancer."

And this is, to the best of my knowledge, still the state of things in prostate cancer today. All prostates are cancerous. A man who lived long enough would eventually be killed by prostate cancer -- a cancer detectable long, long before he actually died. But most men die of other things, because prostate cancer develops so slowly.

Ignoring prostate cancer is in fact a common way to handle it, if the patient is old enough or the cancer is small enough when detected. The technical term for this is "watchful waiting".

A pathologist once told me the likelihood of having prostate cancer is basically you age: 50 -> 50%, 70 -> 70%, ...

103% for my grandfather then

You might want to apply a

    min(calcProp(), 1)

Maybe he has one advanced tumor and one polyp that's about 3% more cancerous than expected.

It's 3% . It resets itself to zero after 100.

I've heard it phrased by a doctor as "Almost every man dies WITH prostate cancer. Almost no man dies FROM prostate cancer."

Anecdotal but both of my grandfathers died from it, one at age 52.

10 year survival rate of prostate cancer is 98%.

https://www.cancer.net/cancer-types/prostate-cancer/statisti... 5-year survival rate for most men with local,prostate cancer combined is 98%25.

Note: That’s if it’s detected.

2.4% of men die from prostate cancer, 33K/year in America. This is easily googleable.

https://www.cancer.org/cancer/prostate-cancer/about/key-stat...

As a corollary, there’s much discussion about the benefits of screening for prostate cancer. The procedure itself carries some risks, and it can lead to operations that add further risks, a significant fraction of which statistically aren’t necessary.

https://en.wikipedia.org/wiki/Prostate_cancer_screening:

“A 2018 United States Preventive Services Task Force (USPSTF) draft adjusted the prior opposition to PSA screening. It suggests shared decision-making regarding screening in healthy males 55 to 69 years of age. The final recommendation for that age group states screening should only be done in those who wish it. In those 70 and over, screening remains not recommended.”

The idea here is to screen people who both have a relatively high risk of having prostate cancer and statistically have long enough to live for it to become problematic, but even for that group, screening still isn’t a clear win.

And this is for the USA, where, in general, sending in the cavalry and doing something is preferred over a “wait and see” approach.

This is highly controversial in the field and is looking like a bad recommendation from the task force. A study has shown that metastatic prostate cancer has increased as a result of this.

Men should get a PSA test in their 40s.

https://www.cancernetwork.com/view/increasing-rate-prostate-...

One of my mentors, age 67 got recently diagnosed with prostate cancer due to a PSA test. No symptomes. His doctor (from the VA), recommended radiation treatement. The treatement fried the nerves in his legs and he now has much trouble in life and doesn't trust a thing they say.

I’m sorry to hear that. However we should be careful not to draw general conclusions from anecdotes.

He got radiation treatment (for prostate!) at 67? That's very odd -- radiation treatment is not recommended for a patient who would be expected to live for more than 10 years in the absence of the cancer.

While there other treatment options. Radiation therapy is a very common treatment to patients of all ages and isn’t odd at all.

Radiation therapy for prostate cancer is in fact odd for a patient expected to live to see the side effects. Standard treatment is nothing for a small tumor, surgery for an advanced tumor when the patient has 10+ years of life expectancy, radiation for an advanced tumor when the patient has short life expectancy.

In fact you are a bit wrong. Surgery and radiation are routinely considered as options for treating the same type of tumor. It is more common to do surgery in younger patients but it is incorrect to say radiation is “not recommended” in these cases. And 67 is not young.

Source: UCSF Prostate Cancer team (#4 ranked by US News & World report)

Did they get second and third professional opinion? You need to do your due diligence with these diagnostic tests in my experience as a patient, it falls on our shoulders to make an informed decision on carrying out invasive preventive procedures (risk - lifelong side effects vs reward - preventing cancerous tissue growth, etc.).

Otherwise you can end up in a situation where you regret not taking action sooner when things have taken a turn for the worst e.g. terminal illness that could have been prevented if caught earlier e.g. metastasizing cancer cells

I don’t know what the right amount of testing is, but proponents of less testing argue that its downsides are worse than its benefits, not that testing doesn’t prevent cancer.

I don’t see how the reference you give addresses that.

> Ignoring prostate cancer is in fact a common way to handle it... The technical term for this is "watchful waiting".

That is not watchful waiting. There is a lot of active watching in watchful waiting, not ignoring. For example you may get looked at every 3 months, either a blood test or an TRUS ultrasound, plus a biopsy every couple years. If it gets worse and crosses a threshold, you might get treated.

This is entirely different from just ignoring it. There are many different grades of prostate cancer and the key is detecting the aggressive types before they metastasize.

Just to clarify what you are describing is called “active surveillance” and is a step up compared to “watchful watching”. Both are ways to deal with prostate cancers.

It depends on risk, diagnosis, and age, but generally with active surveillance you will be actively monitored, you’ll monitor PSA volumes and prostate sizes (and get biopsies), usually on a regular basis. Watchful waiting is much less invasive. When someone is old, their cancer not aggressive and low risk, and is dealing with other health issues, subjecting them to numerous tests for no real benefit is a big stress to both them and their families.

This would be like, high cholesterol may lead to heart disease 5 years from now.. atleast cholesterol can be cut, but yet to start cancer may not be stoppable.

>Ignoring prostate cancer is in fact a common way to handle it,

Most people find this kind of advise difficult to swallow. Ignoring is equated with negligence, conversely heroic efforts (chemotherapy etc.) is glorified even if most of them produces no appreciable positive outcomes.

This is an incredible confusion, and I'm angry to see so many medical authorities and administrations taking the same stance: no, it's never too early to know. The more the information the better everything. What could be too early is to act, supposing that by "act" is meant any predefined medical action. However why would it be any "too soon" for an awareness awakening by the sick individual that would bring a healthier lifestyle?

Last thing I'd like to add, you just have to tell the individual about the trade-off and risks of the early act too, and this additional information will be enough to cancel any supposed danger of the early diagnostics information.

When you think that giving some information is dangerous, then actually it's because you need to provide the targeted individual even more of what info you have.

> it's never too early to know

I don't see this. Suppose, hypothetically, that we could detect right now every illness or condition that you're ever likely to develop in the course of your life. Do you really want to read through that list? You're better off not worrying about it and enjoying your life.

> You're better off not worrying about it and enjoying your life.

I would rather have all of the information upfront so that I can make better informed decisions.

We're all going to die. I'm not going to shy away from that by pretending it won't come.

There's no 'pretence' involved in not reading the list. I'm perfectly aware of my mortality. I just don't see any value in placing bets on what's going to kill me.

Everyone is living with an invisible list made up by them in their minds. This is what drives people to exercise, eat healthy foods, get vaccinated, and wash their hands. This just clarifies the list, perhaps adding some items, perhaps changing the priorities.

I would absolutely read the list, in part because I simply value (self) knowledge. I notice that some people don't value knowledge for its own sake, and have trouble understanding those who make decisions solely for the sake of knowing, or solely to avoid dishonesty toward others, even at some narrow instrumental expense.

But also, I would read the list of because of its instrumental value:

* If I knew I were likely to die in ten years, I would live my life very differently than I do now.

* If I knew I were at particular risk for certain illnesses, I would do what I can do minimize that risk.

I can't really see how not reading the list would require dishonesty towards others.

It's probably a good idea to live your life as if you were going to die in 10 years anyway. The chance of this happening is non-negligible unless you are very young.

Similarly, as far as minimising risk of illnesses goes, 99% of what you could do is what everyone should be doing anyway: eating healthily and exercising.

Fundamentally, the paradox here is that the extra stress caused by reading the list is likely to be much worse for you than the consequences of not knowing what's on the list.

Not reading the list doesn't require dishonesty toward others, but I was making a more general point: There are lots of people who are very ready to tell "white lies" to others for the sake of those others. As it happens, I think they are often the same people who wouldn't read the list. And these sorts of people don't really seem to understand the other sort: the sort who want to know the truth even if it's not instrumental.

---

On the other topics: if I lived like I were going to die in ten years, then I'd have to abandon multiple projects of mine which I expect to take more than ten years to come to fruition. I don't think this would be appropriate unless I actually had a good reason to believe my premature death would come to pass.

I mean live as if there's a reasonable chance that you'll die in ten years. But even so, do you get no intrinsic satisfaction from the work involved? Is there no-one who could continue the projects if you died? If it's 'no' to both questions, then maybe you should stop doing them anyway.

There are always tradeoffs. I get intrinsic satisfaction from the projects. But I think both about the short-term and long-term. If I expected to die in 10 years, I'd do different things, because the balance of costs and benefits would work out differently.

But what if you are like most people and trust doctors to do the right thing and they convince you that unless you treat you'll die. You go along and the doctors damage you. This just happened to a mentor of mine (67 y.o.) with a PSA test followed by radiation that fried his nerves and did nothing for the cancer which he might have lived with for the rest of his life (his father died of prostate cancer at 97). In this case the "cure" was much worse than the disease and the early detection led to the almost fatal result.

I’m very truly sorry about what happened to your friend. That is an awful thing to go through.

Without being an expert on the subject myself, I can’t say whether his doctors recommended the right course of action but he got a bad roll of the die, or whether his doctors made a terrible mistake.

But I think if they made a terrible mistake, then the solution is to make more knowledge available about how to avoid such mistakes, not to make less knowledge available about people’s health.

My father recently went through prostate cancer radiation treatment, and here is our experience. The doctor did not say that unless it is treated, he will die. He did emphasize that with the modern day treatments, the risks and side effects are much lower than that of non-treatment. The radiation treatment was non-invasive, except for the placement of 3 markers inside the prostate to guide the radiation beams. My father did have stronger-than-normal side effects, however after 3 months the side effects have gone. We were actually amazed that cancer treatment was so easy. It is now a waiting game to see whether the cancer has been completely eliminated, but the peace of mind from having had the treatment is worth a lot.

On the other hand, a family friend had prostate cancer many years before, when the radiation treatment was not available, and he had to go through surgery. The surgery caused strong side effects, and also turned out to be not successful, as the cancer spread to his bones after 10 years, for which he is now receiving further treatment. In this case, where the loss of quality of life was high, it's not as easy of a choice.

Actually the side effects of radiation are often similar to surgery in the long run. Surgery is “front loaded” and may be followed by some recovery of function over a year or more. Radiation is “back loaded”, where you see the effects creep in over time. It all depends on a number of factors but it’s not that useful to compare short term.

I’m glad to hear you dad is doing well.

Nonsense. Catching cancer prior to stage 3 is HUGELY important. With prostate cancer it can be cut out or irradiated with a high cure rate at stage 2. Once it spreads though you are in a very different course.

I think you're talking about cancer screening rather than the hypothetical in my post. I was not suggesting that no-one should ever get screened for any illness. But it's a balance. Too much screening and testing can be just as harmful as too little - or perhaps even more so. Prostate cancer is actually a classic example of this (see e.g. https://www.health.harvard.edu/healthbeat/the-pros-and-cons-...)

Your hypothetical includes every illness and thus, cancer. It is extremely helpful to detect cancer early.

The prostate cancer field is rapidly evolving, and the “controversy” over PSA testing in the US over the last decade is looking like a big mistake. See for example https://jamanetwork.com/journals/jamasurgery/fullarticle/268...

>Your hypothetical includes every illness and thus, cancer.

I think there's a quantifier scope error here. I was saying "you don't want to see everything on the list", i.e. "it's not the case that for all x, you want to see x". You seem to be reading this as "For all x, you don't want to see x". Whatever the right answer is for specific cases (such as prostate cancer), I'm certainly not saying that all testing or screening is pointless.

The paper you link to has a grand total of two citations listed on Google Scholar.

It’s a comment by the chair of the #4 ranked prostate cancer department in the country. Here’s another: https://jamanetwork.com/journals/jamaoncology/fullarticle/25...

You changed your statement. What you said was “Do you really want to read through that list? You're better off not worrying about it and enjoying your life.” This unambiguously refers to the list in its entirety.

No, you're still making the quantifier scope error. I'm saying you'd be better off not reading the full list. It doesn't follow from that that you'd be better of without knowing about any of the items of the list. Your mistake is anbalagous to inferring (B) from (A):

(A) John doesn't want to eat the whole pie.

(B) John doesn't want to eat any of the pie.

I'm saying that you're better off not eating the whole pie / reading through the whole list. It doesn't follow from that that you're better off without any pie / without knowing any of the test results on the list.

That's why the list in my hypothetical scenario is comprehensive. If I was saying that you'd be better off not knowing anything, then my hypothetical scenario could just have been "you get some kind of test result giving you information about some aspect of your health", rather than an unrealistic scenario where you get completely comprehensive information about your future health.

You are misusing academic language to mask a modification to your claim under interrogation. You specifically argued against “an awareness awakening by the sick individual that would bring a healthier lifestyle“ by stating it is “better off not worrying about it and enjoying your life.” You are now attempting to amend that claim by saying well of course you’re in favor of knowing about the bad things.

So what does this mean, that you actually support looking at a hypothetical comprehensive list, just that it should be sorted by severity so you don’t have to sweat the small stuff? That would be a fundamental modification of your original claim which had no such qualification.

My claim is consistent and perfectly simple. I'm saying that you'd be better off not knowing everything about your future health. It doesn't follow from that you'd be better off not knowing anything. As you seem to have difficulty understanding that, I've been trying to spell the logic of it out in explicit detail. For reasons I don't understand, you appear to interpret that as a modification of what I originally said.

What exactly would you be better off knowing? In general, that's a complex question and I don't know the answer. But certainly there are clear examples of things that are worth knowing (e.g. your weight, your blood pressure, whether or not you have TB ...)

>by the sick individual

I did not specify that the individual in the hypothetical scenario was sick.

Now you are claiming you didn’t argue against that claim you responded to, which specifically referenced a “sick individual” achieving an awareness “that would bring a healthier lifestyle.”

Indeed your claim was clear and simple: you disputed it, replying it was better not to worry about it and “enjoy your life.”

You have simply dressed up poor reasoning regarding “you’re better off not knowing” by pretending you were only referring to the things not worth knowing, not the things worth knowing, the other part of the set of all things. This is spurious argumentation designed to distract from the fundamental shift in your claim — that of course it is never too early to gain awareness of medical conditions that could motivate lifestyle changes and inform choices.

In the end I am glad you came around to agreeing with the comment, if by a circuitous route.

The quoted claim that I responded to was the claim that "it's never too early to know". Any my claim was made in relation to the hypothetical scenario that I spelled out, where it was not specified that the individual in question was sick.

I think you think I'm changing what I'm saying because you're still making the quantifier scope error. If you read through my comments paying more careful attention to the quantifier scope, you'll see that I've been saying the same thing consistently. I can only make sense of your responses if they are objections to "for all x, you're better off not knowing x", rather than to what I actually said. This misunderstanding is evident from several of your first comments. E.g. "Your hypothetical includes every illness and thus, cancer", and "This unambiguously refers to the list in its entirety." These replies only makes sense if you imagine that I'm saying that you don't want to know anything on the list. But this simply isn't what I said. Or at least, it's the least plausible interpretation of my original comment, and inconsistent with the explanations I've repeatedly made of what I meant.

I don't know why you are so reluctant to accept this. Early in this thread I politely pointed out the quantifier scope error in your interpretation. And the wrong interpretation that you insist on attributing to me has me saying something implausibly ridiculous (i.e. that all medical tests are bad!) Go back to my examples (A) and (B) earlier. Do you have difficulty understanding that (A) does not entail (B)? I doubt it. So why is it difficult for your to understand my claim about the list? I'm baffled.

The pie analogy is a good one. Every piece of the pie is nutritious and worth eating (let's say). Similarly, every item on the unrealistically comprehensive list of medical information may be useful in and of itself. But just like you can have more pie than is good for you, you can have more information about future problems and risks than is good for you.

I pretty much agree with your points. But this is not what we see in reality today.

I believe that part of today's problem is knowledge, interest and incentives.

- About 40% of patients (in general) do not care enough about their health and delegate all decision making to the doctor.

- I am simplifying here: If you ask a surgeon about the best therapy for your cancer, the answer will most likely be surgery. If the same patient would ask a radiologist, the answer will most likely be radiation. Which we might attribute to people more likely to believe in their own line of work. But in reality this might be more influenced by doctors being financially driven by their administrators to maximize patient throughput.

Fortunately these decisions are usually not done by the individual surgeon or radiologist but by a cross-disciplinary team during rounds and by input from wide long-term studies categorising the tumor type, treatment options and outcome.

For metastasized cancers yes. But for primary cancers? Not such much.

Patients need to step up and actively talk to multiple doctors if they want to get a complete picture.

It's just hard to take in that info.. Your average patient is not really capable, especially when delivered life-changing information and requiring THEM to decide what life-changing action to take. Most in that situation defers to what the physician recommends, which brings us back to the current situation.

One root problem here is the lack of a firm connection between test result and long-term prognosis. You can have a supersensitive test, but if the prognosis varies wildly anyway and the possible procedure to do carries significant risk, the test has limited value.

One general rule is that you should not order a test unless you're prepared to act on it, and the guidelines for when to act on the PSA levels are still debated.

There are lots of other tests and pathologies and remedies that make sense to screen for (that can, like you say, make the patient go for a more healthy lifestyle etc).

This is outdated. PSA is a very valuable test as it can flag you for new tests that can be performed short of a biopsy (4kscore, genetics, MRI, ultrasound). And biopsies are getting better at detection as well.

I think that your premise is that the knowledge that the doctor would have to pass to the patient in order for the latter to make enlightened choices would require squarely a long and tedious medical training.

To which I would suggest that

1/ no, the knowledge to have for this particular test results, likely (and less likely) prognoses, and the associated possible medical acts and risks, is not equivalent to a full medical training, as it is a tiny bit of one specialty. But I acknowledge that it may require quite some time.

2/ there is no need to apply the same policy to every patient, and you can choose to only allow tests to the patients who went through the basics training evoked in 1/.

In the end, if somebody wants to go through the process to get the knowledge to be able to deal with the information, why to deny it?

Plus, that would make a nice incentive to get people to know better their own body.

Well I agree fully that there are patients who are smart and could take in the info (for that matter, lots of doctors also end up as patients), and I'd hope their treating doctors give them any info they ask for and get them involved in the aspects. After all, in this specific case I'm pretty sure you can get a PSA taken by yourself even and then the cat's out of the bag.

But in a broader sense, what I was thinking of was that when faced with a shocking piece of info ("you might die and there might be nothing we can do about it" etc.), most people don't stay very composed - there are several different reactions and phases and one is certainly "I want as much information as possible and I want to be involved in all decisions" but I'd argue it's not the most common reaction and even in that case, it's a crisis reaction and maybe not as logically driven (or productive at all) as it might seen at first.

So then you'd first have to figure out how this specific patient would react before deciding to do the screening and if you just guess, you'd probable be criticized at some point, so you instead make sure you follow the national plans and recommendations..

Then the (sad) fact is that you usually have maybe 15 minutes allocated in primary care to say hello to a new patient, listen to the symptoms or concerns, examine, make a plan, inform the patient, say goodbye, dictate the journal. You can't spend hours educating the patient. I'd wish this was different (but then again that applies to any service interaction, even your car mechanic or whatever).

I totally understand...

I think there could be solutions, like:

- proposing bundles formation + test(1), of course much more expensive than just test, but allowing access to a broader range of tests.

- new job description, "medical teacher for citizens", giving (possibly customized) formations to people (and documents certifying they passed), and then these certificates would be useful later to know which patients already understand which aspects of medicine.

I think that would make nice ideas for startups, and I for one would be a customer.

As for the "emotional" aspect, when receiving shocking news, I don't think that withholding information is a solution, quite to the contrary. In a lot of cases, people don't feel well and imagine the worse, but they actually are fine. Other people feel good and actually are very sick. If an information leads to bad diagnostics, they should know, because if not now it would be required later anyway. If the information does not lead to a 100% accurate diagnostic, just quickly get sure that your patient understands basic stats/probas, and then explain to them why the diagnostic cannot be certain and why some benefit/risk trade-off holds.

Any of the "formations" evoked above could include some lesson on how to deal with bad news about oneself.

(1) of course I mean "medical test" here, like the ones to guide diagnostics, not "knowledge test", although these too would be useful at the end of the formation.

PS: the 15 min/patient thing is a huge PITA, so maybe my ideas are doable only in private clinics. Even the "medical teacher for citizens" is completely outside of what is done (currently) in public health.

Prostate cancer is somewhat unique by having a very sensitive blood marker (PSA) being available which can be monitored easily over time.

And yes, there is an (I would say) ongoing debate about the value of using PSA to detect early cancers. Obviously detecting cancer early is a win. But the downside of this early detection is over-treatment of low-risk cancers.

Standard therapy for prostate cancer is the removal of the prostate, but this surgery has a somewhat high (up to ~10-15%) risk of impotence and incontinence (depending on the quality of the surgeon), which can obviously impact life quality quite massively.

Current strategy (in the US) seems to basically stop broad usage of PSA testing, which gets rid of the problem of detecting low risk cancers, but at the cost of delaying the identification of high risk cancers. This is visible in the falling rate of newly diagnosed prostate cancer patients in the US.

This feels like not solving the actual problem (distinguishing low risk from high risk tumors) but glossing over the problem by not actively working on detecting it anymore.

> but at the cost of delaying the identification of high risk cancers. This is visible in the falling rate of newly diagnosed prostate cancer patients in the US.

Importantly, it doesn't seem to affect mortality rate of prostate cancer, nor all cause mortality.

People focus a lot on 5 year survival rate, but sometimes they don't really understand what this means. If I die at 75 does it matter if my cancer is detected when I'm 68 vs 73?

I tend to agree that this is not such a relevant topic for the average prostate cancer age group which is 70+. Here most might die with prostate cancer but not from prostate cancer.

But in the lower age groups 40-60 early detection should IMHO be the aim.

> If I die at 75 does it matter if my cancer is detected when I'm 68 vs 73?

Yes, it matters in both directions.

One way is that the cancer might cause you to suffer in other ways, e.g. by metabolizing all of your food, causing you to lose large amounts of weight. If this is addressable (not at all a sure thing!), then knowing earlier is probably better.

The other way is that you might not be suffering. In that case, given that your death is fixed, knowing earlier is obviously worse.

I've never seen someone die of cancer without being treated beforehand. I understand it's a horrible, painful death. That said, the treatments we apply to someone dying of cancer also make for a horrible, painful death; there definitely is a point at which the treatment is worse than the cancer.

Another wrinkle is that treatment may give you a few horrible months, then a few not-so-bad-years before your cancer comes back, and then the horribleness resumes. Those years in the middle are worth something, even if the time at which you die is fixed.

If we ignore brief-to-medium remissions, and the hypothetical patient's time of death is fixed, then the obvious recommendation is to avoid all treatment and commit suicide when your quality of life drops too low. But the uncertainty we have in reality makes that difficult.

Makes me wonder if there are similarly low risk medication that fight cancer.

With some specialized exceptions, there isn't. Cancer medication has serious side effects.

Immunotherapy, where drugs target specific mutation mechanisms, is making massive improvements lately. I have seen bone scans from metastasized patients before and after, where most metastasizes were gone after a couple of weeks of treatment. Unfortunately today these drugs only work for a small subset of all tumor mutations, so it will not work for everyone and even if it works, the tumor might mutate and kill you anyway.

>Prostate cancer is somewhat unique by having a very sensitive blood marker (PSA) being available which can be monitored easily over time.

Cancer antigens such as PSA and CA-125 can also increase due to non-cancerous causes. Pretty much all of them increase in any kind of inflammation whether it is due to bacteria or something else and more. So their main use is getting a baseline once the cancer is diagnosed and monitoring it later on.

Funny story, a professor once had a patient with prostate cancer, treated and cancer free afterwards. Every 6 months the patient would visit for screening and his PSA was through the roof( think >1k while normal levels are at most around 3ng/mL). After performing CT scans etc the patient was found cancer free. Another PSA test would return normal after a couple days. This story repeated several times with the professor slowly sliding into madness from it.

Turns out the patient was getting anxious about the screening the day before so he smoked some weed which increases PSA secretion. And of course weed is illegal here so he didn't want to admit it.

Should have stressed the "over time" part more. Yes PSA is sensitive to sex and sport (esp. cycling), and also to inflammation. Plus you personal PSA value depends on the actual size of your prostate.

That's why getting an early PSA baseline is important, so you know what value is "good". Also you might not want to take drastic action based on a single "bad" PSA.

No, you got it wrong. You get a baseline PSA measurement AFTER the diagnosis. That way you can see if the patient responds to treatment and also monitor for recurrence.

Cancer antigens are NEVER to be used for diagnosis. Chemotherapy is too destructive to be used without 100% certainty. We've had a woman with high CA125 and it turns out it was tuberculosis in the reproductive system... Everyone wanted to start chemo, the symptoms matched etc...

In my father's case, our family doctor requested a prostate cancer screening after seeing PSA levels from regular blood tests rise over the course of a year. We received the cancer diagnosis after the screening.

PSA is definitivly used for early screening prior to diagnosis [1].

But we might use the word baseline for different things.

As PSA is influenced by the patients physiology and activity [1], it can be helpful to understand what the non-cancer baseline/standard PSA value for a specific patient is, this would need to be established by multiple tests over a couple of years. This can help in distinguishing noise from signal later.

After surgery the PSA baseline is zero (by definition, the generating organ has been removed). Any value above zero indicates either metastasis in other body parts or a really bad surgeon.

After non-surgery primary treatment (radiation, ...) the PSA does not (necessarily) fall to zero, so here one takes the lowest value after treatment (with a grace period) as the baseline.

[1] https://www.cancer.org/cancer/prostate-cancer/detection-diag...

It is also visible in the increase in metastatic prostate cancer.

I’ve spoken with the chief surgeons of two major prostate cancer centers. They agree this was not a good recommendation by the US task force.

Also I should add that the risk of impotence / dysfunction is much higher with late-detected cancers.

https://jamanetwork.com/journals/jamaoncology/fullarticle/25...

Early detection of prostate cancer with PSA testing and digital rectal exam: https://www.hardingcenter.de/en/early-detection-prostate-can...

> With or without screening, 7 out of every 1,000 men died from prostate cancer over a time period 11 years.

But in the screening group additional men were harmed by side effects of surgery.

I am not sure what percentage of patients still require surgery as opposed to the more modern radiation treatments. My father's radiation treatment was painless except for the placement of the 3 tracking markers in his prostate, and although his side effects were more severe than most, they have disappeared after 3 months. So if prostate cancer treatment does not affect eventual death from the cancer over 11 years, then the questions are whether the treatment improve QOL during the 11 years, and whether the onset is delayed within that 11 years.

Stomach cancer, for one, is easy to remove surgically if detected early but it does not exhibit symptoms until it is often too late. I suspect that early warnings would trigger targeted endoscopy procedures. The pathogenesis of prostate cancer may not be representative of other cancers.

Same with bowel cancer. Easily treated if found early. There are at home test kits which can detect small amounts of blood in stool -- often an early warning sign. And while unpleasant sounding, colo(no)scopy is pretty uninvasive.

This is widely discussed in medical circles, but the real problem is a different one: It's sometimes hard to know what helps and what doesn't.

You may see something that may lead to a cancer. But you really don't know. It may be a) harmless, b) lead to a cancer, c) a mistake in your test. If it's b) then treating it early is good. If it's a) or c) then treating it early will ultimately harm the patient. If your test finds mainly a) and c) then your test may ultimately do more harm than good.

Isn't this the idea behind watchful waiting? You have an early signal so you follow up with periodic tests to see if it goes away or shows signs of malignancy.

Eventually we'll have studies that show the conditional probability of different cancer outcomes based on these early signals, and from there we'll have a protocol to get the best outcomes, reducing the chance of malignant cancer while minimizing cost and medical intervention.

it is at minimum an early warning for lifestyle change

Even if you could predict with certainty that the patient is going to develop cancer in 10 years, and you know of a course of treatment you could undertake that will ultimately prevent that cancer developing, you still may not be able to say whether this is the best use of the patient's time and resources today. (And the patient can't be sure either.)

So the best course to take seems to be a combination of the probabilities of each case along with the risk tolerance of the patient, thus it is not a question the medical community can answer, but needs to be an individual discussion with each patient.

>That at least was the general topic of the article. The question it raises is interesting: is it sometimes too early to know. reply

Bit like near earth objects, we can detect one far far away and whilst could be 95% sure it will hit, either way, unable to do anything to it until it gets closer. But always good to know ahead of time so can prepare and eventually able to deal with it further out.

I have a SNP (according to ancestry) that gives me ~5X the chance to get prostate cancer. What treatment is available for prostate cancer, besides debilitating surgery?

Chemo and radiotherapy, the whole trifecta. Some new ways of implanting small radioactive disks straight into the prostate with a minimally invasive procedure are being developed as well.

Someone I know had robotic keyhole surgery and they were up and walking about in a week. That was a man in his 60s with mediocre health. He went to the Henry Ford Medical Centre.

Keyhole is the key here to walk out asap. The "roboter" is not delivering that much in terms of quality of outcome or speed of recovery.

Surgery, done by good surgeons, has low (single digit) complication rates.

Tip: Ask your surgeon how often he does this specific surgery. Removing the prostate requires foremost experience to not severe any nerves surrounding the organ, which are important for potency and continence.

As you would not want your cars brake firmware to be written by someone who usually writes marketing apps, you do not want to get this surgery from anyone who has not specialized on it. There are specialists who do this surgery >200 times a year.

I'm in my mid thirties, I'll look into PSA, and my father has prostatitis, but no family history of prostate cancer(my grandfather died 86 years old, but lived a much healthier life than me or my father).

So I'll definitely keep it under observation, I just hope those percentages will improve in the next decades.

Depending on personnel preferences, you might want to get a regular PSA check once a year to ensure you catch it early to give you runway to evaluate treatment options. It's better to be able to assess the situation and contact multiple experts than having to rush if detected to late.

Triple therapy is what a relative of mine underwent after getting Gleeson score 9 (bad but not metastasized) prostrate cancer. He hadn't been doing regulator screenings or would have caught it earlier. The triple therapy (radiation + hormone + brachytherapy, basically little radioactive implants) sucked in terms of side effects at the peak, but it hasn't been long term debilitating, amd he's now doing well in remission.

First, you should be focusing on detection. You probably know about the PSA test and biopsies, but there is also a more sophisticated 4kscore blood test. MRIs and TRUS ultrasounds are also diagnostic tools.

If it’s detected then they will biopsy it and grade the cells to see how aggressive it is. If it’s not aggressive they will just monitor it without treatment.

If it comes to treatment, and you’ve caught it at stage 2 (hasn’t spread), then it’s either cut out your prostate or zap it somehow (e.g. localized radiation).

For “younger” patients they usually recommend surgery. First, with early detection it is less likely to be debilitating. They can spare the nerves that control erectile function, although they can still get messed up and there is still a big chance of some decline in function. But it’s a better outcome than older age brackets or larger tumors — keep that in mind when looking at overall stats.

The reason they recommend surgery is the long term side effects are similar to radiation and if they don’t get it all with surgery, they can go back in and mop up with radiation. Whereas the reverse doesn’t work as well because of tissue damage.

(Note: some people are drawn to alternative ways of zapping it like proton therapy in the hopes it will have less side effects but so far, nothing conclusive.)

I’ve studied this topic a lot and consulted with top prostate cancer centers of excellence. Key points:

- Disregard what you may read about PSA testing / screening being “more harm than good”. This was a relatively recent recommendation in the US by a non specialist task force that is looking to be bad advice. Studies now show it has led to an increase in metastatic cancer.[1] You don’t want that.

- Every man should get their PSA checked by 45, or earlier if it runs in your family. It is a simple blood test. We are lucky to have a tool like that at our disposal; not always the case for other cancers.

- Prostate cancer treatment can have major impacts on quality of life including sexual function. You are much better off getting treated before it reaches stage 3. Quality of life is better. This is not reflected in mortality stats.

- People do die from it and it is a slow and painful death like most cancers. About 2.4% of men die from prostate cancer.[2] With early detection it is very treatable, however, even curable.

- There are advances in screening techniques. PSA is an imperfect but easy and cheap initial screening tool. Doing it early can also establish a baseline. If it’s abnormal it just opens up a conversation and more screening options. Biopsies are also more accurate these days.

Men, go ahead and get your PSA test.

[1] https://jamanetwork.com/journals/jamaoncology/fullarticle/25...

[2] https://www.cancer.org/cancer/prostate-cancer/about/key-stat...

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