Should you check your PSA? Prostate Cancer Testing Isn't Straight Forward - Dr Gill

[@wolfmoon5720]

During my Masters I had to write a paper about pros and cons of screening tests (not specifically PSA) and I was surprised by a lot of the statistics for false negatives and false positives as well as overtreatment for cancers that would never become clinically significant as you mention. Going in I thought of course surely it’s always valuable to do these tests but actually it can be far more nuanced from the clinical point of view. I think the fact that you included that you and other knowledgable professionals wouldn’t do this test without good reason is quite illustrative! Thanks for another informative video as always!

[@DrJamesGill]

You are welcome. The number of discussions I have to have with patients, not only about PSA where the answer is “Unfortunately medicine isn’t black and white like that. That test / treatment / drug doesn’t quite work that way in the real world, and might actually make things worse for you”

[@Maurus200]

I’m young when considering prostate cancer. My father had prostate cancer and I heard doing an early PSA test could help set a baseline for me specifically. I was doing a lipid test anyway and even though the Dr was skeptical he did add it to my test. I’m not the type to demand that type of thing. I didn’t think he was going to do it. Came back normal at least!

[@salem-aa]

Thanks for your explanation

[@DrJamesGill]

Glad it was helpful!

[@roodersclive8654]

Really helpful, thanks. I'm 54 and have been wondering about this on and off for a while but I dont have any of those symptoms and no family history, so on that basis I'm not going to have one. N.B the last time I looked at the NHS website I didn't find it particularly helpful. It basically said you're at risk in your 50s and to get checked.

[@DrJamesGill]

Glad you found it useful. I think to some degree, there is a SYSTEM problem of “Just test people then we can’t be sued” but that doesn’t look at the problem of what to do with the test results in all the people who did NOT need a test

[@aaronquinn311]

How are baby Gill and Momma Gill doing?

[@robouser83]

A few typos in the overlay, says "sympoms" instead of symptoms

[@DrJamesGill]

Ah damn it. I’m going to blame a baby and lack of sleep #patheticexcusetime 😂

[@solomon835]

Aren’t symptoms an indication of advanced cay?

[@DrJamesGill]

Clinically significant case certainly

[@chuckoneill2023]

Is there a genetic screening test? To the best of my knowledge, I've no family history of prostate issues.

[@DrJamesGill]

You can test for the BRAC2 gene, as that confers a 20% risk As in 1/5 with BRAC2 will develop prostate cancer, but that test is normally done when someone is at risk

[@chuckoneill2023]

@@DrJamesGill Thanks. Some years back, my physician told me the PSA test was available, but he didn't recommend it. I think this was because the insurance company listed it as a "screening", but the doctors knew perfectly well that it isn't.

[@enderefecerit1980]

@@DrJamesGill Thank you for the nice video. Have you heard about the Stockholm3 test which checks multiple protein and genetic markers for prostate cancer?

[@TenkoBerry]

3 hours left to Go, This gonna be Quite Interesting 👌

[@TheProactivePatients]

What do you think about NCCN's guideline for average risk men 45 and up to consider PSA testing every 3-4 years.(those with a family history and/or genetic risk are recommended to do do a PSA annually starting at 40 or adjusted by earliest age of dx in the family)? It still sounds to me as if NCCN is treating this as a screening tool. To me a diagnostic tool is one in which a positive test result gives you a diagnosis. PSA doesn't do that. It is a screen because you still need other tools to verify the result. Just like an AFT/triple/quad screen in prenatal testing. Not necessarily the most effective screens, but they are still screens. Biospy, like amniocentesis, is a diagnostic tool. When these tests are abnormal, you have a diagnosis. PSA doesn't do that. No screens do. Screens just tell you who might need further workups. Yes there are good screens and bad screens, but often you use the tools at hand. We used to use a quad screen for a prenatal tool, now I never would; I'd use a first trimester screen, or now NIPS as a screen. They have gotten much better over time, but none are the diagnostic tool. Maybe we need a technology upgrade from the PSA, it's not a great screen, but it is what we have, which is why it is recommended to those who have an increased risk for prostate cancer. That doesn't mean it's a great screen. But it is definitely not a diagnostic test.

[@DrJamesGill]

I HONESTLY this that PSA testing has become a political issue almost. Second commonest cancer, and commonest cancer in men… with no reliable screening tool - unlike breast cancer screening - and that looks bad, so let’s use this test instead and we’ll make the test result issue someone else’s issue

[@TheProactivePatients]

@@DrJamesGill it would be nice to include the stats though. What is the rate of false positives? What is the sensitivity? What is the positive predictive value. What percentage of prostate ca picked up by psa? Yes, its great to talk about the adverse outcomes, but its not a fully informed decision withought the numbers.

[@DrJamesGill]

A bigger issues is not the false positive, but the 20-50% of cancers detected which are considered to be UNLIKELY medically significant. This was a stat discussed. As we can’t put that information back in the bottle, and I think it would be very difficult to counsel against treatment in an otherwise health person

[@TheProactivePatients]

@@DrJamesGill there is the same discussion about breast cancers (really DCIS) being over called and over treated. I get that, but from a high risk patient point of view, I would rather have things over called than missed. The other thing I run into from a clinical perspective (and maybe a more cultural issue in the US) is that men are less likely to report symptoms and get things checked (or even go to an annual appointment if they are otherwise well). How many treatable prostate cancers are missed or caught at a late stage because they didn't get things checked when they should have? I agree that it is a balance. I realize that I also have the bias from working mostly with the high risk patients. But that being said, the identification of who is high risk is severely underdiagnosed. Most of the patients I see for genetics are referred because they already have a stage 4 prostate cancer. I don't get the referrals based on family history or even the referrals for those with a "high or very high risk" non-metastatic prostate cancer (as recommended by NCCN for genetic testing). Many PCPs in this treat these guidelines for average risk patients with very little discussion (just a "do you want a PSA test" without a full discussion). And very few in this area realize that prostate cancer could be familial or hereditary and who should be getting screened. It's likely due to our health system on this side of the pond, but the stratification of high risk versus average risk is not done well over here and often the responsibility is put on the patients to be proactive and knowing what questions to ask rather than the providers offering a nuaced discussion.