Discussion about this post

User's avatar
Overcoming Bias Commenter's avatar

isisdave:

I'm so sorry to hear that you're in this stress-producing situation. My 86 year-old mother, as she was instructed to do, went faithfully for her annual mammograms. This year, they finally found something in the right breast. Ultrasonically-guided needle biopsy showed a well-differentiated non-invasive cancer. Simple mastectomy was recommended. Well, the bright old girl said, "I'd rather have a flat chest that one breast, and I'll eliminate the chance of this ever happening again." Mammogram and MRI of the left breast was normal. She talked the surgeon into bilateral mastectomy. Histologic exam confirmed the one known cancer in the right breast, and *three others* on the left. The surgery was far more threatening to her survival than the cancers, and *she should never have known about them anyway*. Had she done what the tests indicated were necessary, she would have retained 75% of her cancer load.

If you haven't done so, read the first comment in this thread, especially the links. Your comment "known cancer causes a "high" PSA nearly 80% of the time" has no clinical practicality: if you know you have cancer, you don't need a PSA test, unless you plan some unproven program of following it along until it reaches the "interventional" level. You mention better and better blood tests: like my mother's mammograms, sooner or later some test will confirm your prostate cancer, if you keep at it long enough. As the first thread comment confirms, a 59 (or 54) year-old man with a normal PSA has only 6% less chance of having prostate CA than one with a PSA of 4.1-10.

There is *almost* no evidence that metastatic prostate CA patients have greater survival if their treatment includes removal of the primary (the prostate gland), rather than waiting and treating the metastatic symptoms. *And*, the younger men are more likely to have the aggressive, early-metastasizing cell lines, which are usually metastatic when diagnosed.

I have to hope that you did *not* read the first comment, or that if you did, you have good reason to reject it. The stress to which you are subjecting yourself is *known* to decrease suvival (MI's, etc), while the aggressive treatment of prostate CA is not known to increase survival.

Sadly, you are in the position described by Eliezer Yudkowsky (I've substituted "ignorance" for the original "stupidity"): "The happiness of ignorance is closed to you.  You will never have it short of actual brain damage, and maybe not even then.  You should wonder, I think, whether the happiness of ignorance is optimal - if it is the most happiness that a human can aspire to - but it matters not.  That way is closed to you, if it was ever open." And it was.

Expand full comment
Overcoming Bias Commenter's avatar

A lot of public-health medicine is based on statistics, but the sample size I care about is n=1.

The fact is, PSA is a test of limited value because it is not very specific; i.e., a "high" number correlates with presence of cancer < 20% of the time. It is, though, fairly sensitive: known cancer causes a "high" PSA nearly 80% of the time.

So here I am at 59, five years after my initial PSA came in at 7.0. Negative biopsy, and it's STILL 7.0. So either I haven't got cancer, or the biopsy missed it and it's not very aggressive. Sure wish I knew which, as I plan to live past 90.

Better tests are available. The PCA-3 is supposed to be 97% specific, so it appeals to people in my situation. Not approved in the US but available at about $450. I just read that Austria started using it regularly this summer.

Another group is using PCA-3 and five other DNA markers; it's supposed to be even better.

And a big study of EPCA-2 is coming up.

I think the focus ought to be on "which test to screen with at what age, and in the presence of what results from earlier in life".

Expand full comment
9 more comments...

No posts