Tag: Prostate Cancer

Personal and Professional Choices in PSA Testing: A Teaching Moment

Jun 6, 2025

By KELLI DEETER

I was intrigued by Daniel Stone’s piece on THCB in May titled “Biden’s cancer diagnosis as a teaching moment”. In my practice as a board-certified nurse practitioner, I am frequently asked about prostate specific antigen (PSA) testing by my male patients.

Nursing practice and medical practice often get blurred or lumped together. In the state of Colorado, nurse practitioners practice under their own license, and can independently diagnose and treat patients. In some settings where I have worked, I found myself frequently correcting patients who refer to me as ‘doctor’. “I am not a medical doctor, I am a nurse practitioner,” is repeated by me multiples of times per day. In this discussion of PSA testing, I want to share my decisions to order or not to order PSA testing for individuals, based on my nursing training.

It is important to refer to the guidelines for PSA testing recommended by the US Preventive Services Task Force (USPSTF), and published by the Journal of the American Medical Association (JAMA). The last updates made to the guidelines were in 2018. It is key to remember that these are guidelines, and that medical doctors, physician assistants, and nurse practitioners use these guidelines in their consideration of the patient. In nursing, a holistic and team approach with the patient’s preferences, history, cultural considerations, and desired outcome are all weighted in decision making for assessment, testing, referral, and treatment. Guidelines are just that, a GUIDE, not an absolute.

Guidelines state that for patients aged 55-69: Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction… Clinicians should not screen men who do not express a preference for screening. And for patients aged 70 and older: The USPSTF recommends against PSA-based screening for prostate cancer. This does not mean that we as providers should not test men younger than 55 or older than 70. We need to look at each patient case independently of one another and not lump everyone together.

Additionally, patients may not know how to “express a preference for screening”. It is imperative that providers have the allotted time to explore their family history of prostate and other cancers, explain to them the benefits and risks of testing, listen to and discuss their signs and symptoms, perform a digital rectal exam (DRE) if appropriate and agreed on by the patient, take into consideration their medication regimen and their age, as well as if they would want treatment or not. Certainly, if they are symptomatic, and a new medication for their symptoms is being prescribed, or if they are symptomatic and a DRE is obtained that is abnormal, a PSA should be obtained with the patient’s approval to establish a baseline, and a follow-up appointment made with repeat labs or referral, if desired by the patient. If there is a family history of prostate cancer, an early PSA screening test to establish a baseline might be preferable. Again, patient preferences must be taken into account.

People have very different feelings about western medicine and about what they want for themselves and their bodies. We must realize that just because someone has an ever increasing PSA with or without symptoms, they may not agree to a DRE or to referral to urology, surgery, or oncology. As a provider, we should obtain a refusal of recommended care. It is ok to not want testing, follow-up, or treatment, no matter one’s age. In Biden’s case, there had been no PSA testing since 2014, during his vice presidency. The fact that no reason was given is irrelevant, in 2014 he was 72 years old. Guidelines are not to test starting at age 70. The PSA level if drawn may not have aƯected his health outcome or treatment, but it may have affected the outcome of his nomination for the presidency, thus politicizing nursing and medical practice. Pointing fingers now at the past changes nothing. I agree with Stone, that this is a teaching moment: advocate for yourself as a patient, advocate for your patient as a provider, and consider that so much of one’s health is a personal choice and that it should be honored and protected.

I agree with Peter Attia’s contention in his May 24, 2024, A timely though tragic lesson on prostate cancer screening, that the PSA screening guidelines are out of date; the last revision was in 2018. Attia indicates many men remain healthy and live well past the age of 80, and aggressive cancers if caught early and treated, will better benefit the patient’s quality of life and length of life. I would also argue this is true of screening earlier in life, at age 50. Access to health care is an issue for many in our society. Marginalized populations such as the indigent, homeless, geriatric, mentally ill, and incarcerated experience greater disparities, and have a higher risk of missing any PSA testing at all. In my work as a nurse practitioner in the correctional system, for individuals entering jails and prisons this is often the first time they have ever seen a healthcare provider. These individuals often have a history of indigence, homelessness, and/or mental illness. Additionally, new cancer diagnoses are increasing and for men; 29% of new cancer types are prostate.

Age 50 is a milestone for most individuals, and they know they are supposed to get screening for colorectal cancer at this age as well as other screening tests. Consolidating care by capturing a PSA at this same time would establish an early baseline; there is never a guarantee that a patient with healthcare access issues will ever return for another appointment, due to finances, transportation, fear, or other factors. Another consideration for revising the PSA screening guidelines is lowering the threshold for PSA levels based on patient age that drive referral to urology for imaging, and putting simple language into the guidelines to look at a two-fold increase in PSA over 6-12 weeks as likely urgent referral to urology. Initiating early watchful waiting with PSA screening has the potential for saving more lives and maintaining desired qualities of life.

Kelli Deeter is a board-certified family nurse practitioner with 12 years of experience in geriatrics, rehabilitation, correction, women’s health, mental health, and complex chronic care.

Biden’s cancer diagnosis should be a teaching moment

May 30, 2025

By DANIEL STONE

Joe Biden’s metastatic cancer diagnosis brings together two controversial issues: PSA testing for prostate cancer and presidential politics. To understand what is at stake Americans need basic information about PSA testing, and a frank discussion of the reasoning behind the prostate cancer screening decisions in the former president’s case. The dribble of information we’ve gotten only creates more uncomfortable questions for Biden and his family. The absence of adequate explanation also fails to contribute to public appreciation of these important medical issues.

The prostate, a walnut-shaped gland at the base of the bladder, produces “prostate specific antigen,” or PSA. Chemically classed as a glycoprotein, a sugar/protein aggregate, it leaks from the prostate into the blood, where its level can be measured with routine blood testing.

As men age, the prostate enlarges, increasing PSA levels. Screening tests take advantage of the fact that prostate cancer usually leaks more PSA than normal prostate tissue. And in the case of prostate cancer, the PSA typically rises relatively fast.

Beyond these basic facts, the PSA story becomes hazy. Although an elevated PSA may signal cancer, most men with an elevated PSA have benign prostate enlargement, not prostate cancer. Worse yet for screening, many men with prostate cancer have a mild and slow-moving disease that requires no treatment. They coexist with their disease rather than dying of it. This fact leads to the old adage that prostate cancer is the disease of long-lived popes and Supreme Court justices.

Medical advisory panels view PSA screening with skepticism partly due to the challenges of distinguishing benign PSA elevations from those related to cancer. Confirming a suspected cancer diagnosis requires prostate biopsies that can be painful and can produce side effects. Additionally, once a diagnosis is made, patients who might have coexisted with their disease may needlessly be subject to the harms of treatment, such as radiation and surgery. Finally, the benefits of early treatment of prostate cancer have been difficult to prove in clinical studies.

For all these reasons medical advisory panels have discouraged widespread testing or recommend a nuanced approach with careful discussion of risk and benefits between patients and their

Despite these concerns, the pendulum has swung toward more PSA testing in recent years. One reason is that improvements in radiographic imaging, such as MRI, allow for “active surveillance” that can track early lesions for signs of spread, allowing doctors to distinguish between relatively benign cases of prostate cancer and those likely to progress. Interventions can then be directed more specifically to those at high risk.

In my medical practice, I have generally been an advocate for prostate cancer screening despite the controversy surrounding the clinical benefits. My experience leads me to believe that early diagnosis improves prognosis. But even without improved medical outcomes, patients and their families still benefit from early diagnosis for the purposes of planning. No one wants to be sideswiped by a late-stage symptomatic disease that limits both clinical and life choices.

It’s Money That Changes Everything (Or Doesn’t) For Surgeons

Jan 30, 2025

By MICHAEL MILLENSON

“Money changes everything,” Cyndi Lauper famously sang about love to a pulsating rock ‘n’ roll beat. So, too, when it comes to financial incentives for surgeons, two new studies suggest, although “How much money?” and “What do I have to do?” are the keys to unlocking monetary motivation.

The first study, a JAMA research letter, examined the impact of a new Medicare billing code for abdominal hernia repair that paid surgeons more if the hernia measured at least 3 centimeters in size. Previously, “size was not linked to hernia reimbursement,” noted University of Michigan researchers.

Surprise! The percentage of patients said to have smaller, lower-payment hernias dropped from 60% to 49% in just one year. Were “small hernia” patients being denied care? Nope. Were surgeons perhaps more precise in measuring hernia size? Maybe. Or possibly, wrote the researchers in careful academic language, “the coding change may have induced surgeons to overestimate hernia size.” Ambiguous tasks, they added, “can be conducive to perceptive [cq] bias and potentially even dishonest behavior, perhaps more so with financial incentives at play.”

This being an academic publication, two footnotes informed us that dangling money in front of our eyes can cause people to “see what you want to see” and come up with an “elastic justification” for truth.

If a simple coding change can apparently boost the number of large-hernia patients by 18% in just one year, what about a payment incentive meant to induce more urologists to follow the medical evidence on low-risk prostate cancer and adopt “active surveillance” (formerly known as “watchful waiting”), rather putting patients through a painful and expensive regimen of biopsies and surgery?

A second study, also in Michigan, involved commercial and Medicare-age members of the state’s Blue Cross and Blue Shield plan. However, after three years and more than 15,000 patients, “the payment incentive was not associated with increased surveillance use among patients with low-risk disease,” researchers concluded in a JAMA Network Open article.

Last Couple of Months in Oncology with Dr. Bishal Gyawali: March 2019

Mar 26, 2019• 2

By BISHAL GYAWALI MD, PhD

Hey, I’m back!

Well, you might not have noticed that my blogs were missing for the last three months but anyways, its good to be back. I was having a little time off blogs and social media as I was transitioning in my career but now I am back. Sometimes, it is very difficult to manage time for things that you must do versus things you enjoy doing, especially when these two don’t intersect. For me, these last few months the things I had to do were all bureaucratic while I couldn’t find the time for things I enjoy doing like writing these blogs. But now that we are back, let’s recap what has happened in the oncology world in the year 2019 so far. I can’t cover all of them, but will try to summarise the major events in oncology.

Hundred Foxes’ Howl versus One LION’s Roar

In my country, there is a saying that goes somewhat like the roar of one lion will scare hundreds of howling foxes away. In medicine, I guess, it translates as one good RCT trumps the results from hundreds of observational studies. For patients with advanced ovarian cancer, primary surgery to achieve complete resection is the most important treatment and prognostic factor. However, what to do with the lymph nodes is a question that has troubled the oncology community for a long time. Logically, it makes sense to remove the lymph nodes too because they are the sanctuary sites for cancer cells. However, lymph node dissection carries high morbidity. Although multiple observational studies suggested a survival benefit with lymph node dissection, the LION trial, now published in the NEJM, shows that for women with macroscopic complete resection of primary tumour, lymph node dissection increases morbidity (postoperative complications) and post-operative mortality rates but doesn’t improve survival. I am glad that this trial was carried out and these results will now save many women with ovarian cancer worldwide from unnecessary harmful procedures, but I am also sad that we didn’t answer this question until now and thus, many patients suffered unnecessarily. I hope this LION’s roar scares us from jumping to conclusions based on logic or observational data alone and without RCT evidence in future. Another lesson here is the importance of public funds in supporting RCTs like these.

Don’t Underestimate Patients

Jun 17, 2017• 6

By GEORGE BERGER, PHD

I was diagnosed with aggressive but localized prostate cancer at a major Dutch academic hospital. My parameters were PSA 29 or 31, Gleason sum 4 + 4, and stage T2c. Fortunately, there were no detectable distant metastases. The specialist drew a simple image of my urinary tract and told me I was excluded from brachytherapy, which I had never heard of before, because of the size of my prostate. I had to choose between external beam radiotherapy (EBRT) and radical prostatectomy (RP). How on Earth could I choose rationally while knowing so little about prostate cancer? However, I had studied maths and physics and could learn necessary medical science about my condition.

The Dutch healthcare system was privatized in 2006 by a special arrangement between the Health Ministry and the private insurers. This was the first healthcare privatisation in the European Union (EU). The effect of privatisation was, in my opinion, mixed. By the time I was diagnosed I already had much to distrust about the privatisation.

I sought a second opinion in Uppsala Sweden, where I had spent a lot of time as an academic visitor. Its Akademiska Sjukhuset (The Academic Hospital) has an excellent oncology division. I consulted two specialists.

Prostate Cancer: Not a Good Week

Aug 30, 2013• 11

By James Salwitz, MD

The general practice of oncology seems to come in waves of disease. One week every breast cancer patient is in trouble, another sees multiple new cases of lymphoma or leukemia, the next it as if someone is giving away lung cancer (or perhaps cigarettes) and then three patients with pancreatic cancer end up in the ICU. This week a portion of the 240,000 yearly USA cases of prostate cancer walked in our door. The rush of cases served as a reminder that when it comes to this illness, we have a long way to go.

First, Allen. He is 73 years old and has prostate cancer in one out of twelve biopsies. The cancer has a Gleason’s Score of 6 (a measure of aggressiveness of the cancer tissue: more then 7 is particularly bad), which means it is not fast growing. We recommended that given the small amount of slow growing cancer, Allen should be watched without treatment (“Active Surveillance”). What Allen found so difficult about this recommendation is that his son was diagnosed with prostate cancer just one month ago and his son, who is 49, has a Gleason’s 8 Prostate Cancer on both sides of the prostate, and is scheduled for robotic surgery. More than having cancer, Allen is hurt by the feeling it should have been him.

Then there was Robert and Mike. Robert was in the office at 10:00am for evaluation of his newly diagnosed prostate cancer, PSA blood test 32 (high), Gleason’s 7, with evidence of invasion through the capsule of the prostate gland. Fortunately, because prostate cancer likes to spread to bone, his bone scan is normal. Despite Robert’s relatively young age (66), the surgeon recommends external beam radiation therapy (RT) instead of operating. What is bizarre and makes my head spin, was that at1:00pm, in the same exam room, in the same chair, I saw Mike. He has recurrence of prostate cancer, previously treated with surgery. Now Mike needs RT. Although Robert and Mike do not know that the other has cancer, they have worked together in the same small company for 28 years, and consider each other friends.
Continue reading…

Killed by The New York Times?

Feb 20, 2013• 13

By John Schumann, MD

Readers know that I am skeptical of medical practices that defy logic, or as we say in the business, evidence. Among the most controversial issues that beguile all of us (patients and docs) is this business about the PSA test.

A loyal reader sent me a doctor-written column with the provocative headline “My Patient, Killed by The New York Times.”

First, keep in mind that the website that posted this, Mediaite, is all about the media covering (really fawning and dishing) itself. The purpose of this story, with its provocative headline, sad outcome, and mea culpa tone, is to generate “buzz.”

Then understand that this is a story of one patient who made an informed decision to forego PSA testing, based on the fact that he was an intelligent person without symptoms who’d read the literature (or at least responsible press coverage of said evidence). He did not want to open the Pandora’s Box (literally: crapshoot) that is PSA screening.

Yes, he wound up with advanced prostate cancer and subsequently died. Had he had his prostate removed or radiation to ablate his cancer, and wound up with horrible side effects (impotence, incontinence) would he value the trade-off?

I offer you the counter-anecdote of Ted, who in a discussion with me, insisted that he get a PSA test because his heroes Joe Torre and Norman Schwarzkopf told him to. When it came back at 4.10 ng/dL (threshold 4.00), he went for biopsy (what else to do?) which showed low grade, gland-confined prostate cancer. Fearful of the “C” word, he couldn’t live with the idea of doing nothing (“watchful waiting”) about his cancer. So he chose external beam radiation, with the hope that it would be less damaging than radical surgery.

Can Big Data Save My Dad From Cancer?

Dec 21, 2012• 6

By Colin Hill

My father, Foster Hill, has stage III prostate cancer.

At 69 years old, he is a quiet man who was often told in his younger days that he resembled Muhammad Ali. He immigrated in his twenties to Canada from the small Caribbean nation of Antigua to look for opportunities beyond sugar cane and the tourism trade.

My father became a chemical technician for well-known oil refineries, while staying true to his real passion in life – playing organ music. Every Sunday, as he has since I can first remember, he plays the largest church organ in Sarnia, near Lake Huron, where he lives with my mother.

Like many men of his generation, he has always been wary for the medical system. For decades he avoided the test, known as PSA, that screens for prostate cancer. In September of this year, driven by pain he could no longer ignore, he went to his doctor who discovered a rock-hard prostate gland. The diagnosis, stage III prostate cancer, means that the cancer has already begun to spread, but is still potentially treatable.

Now retired, his long hours practicing the organ are punctuated with doctor visits to receive Lupron hormone therapy. The good news? The therapy is working. For now.

We don’t know what lies ahead. The first round of Lupron therapy is often effective, but a significant number of patients later develop a resistance to the drug.

The battle against my father’s cancer has only just begun.

This is where Big Data in healthcare can become a true lifesaver. Typically, in medicine, we know only what works for the majority of patients, not what will work for an individual. However, with enough data from enough people – we are talking hundreds of thousands, and sometimes, even millions of patients – we can apply analytics to build predictive models to discover which interventions will work. For the last twelve years, it has been my job to make that happen.

As CEO and founder of GNS Healthcare, I oversee a team of mathematicians, biologists, and data scientists as they crunch and decode healthcare data to unlock the mysteries of what treatment will work for specific patients.

My father’s cancer has given these efforts a new urgency and has raised a new question: Can I use Big Data to save my father’s life?

Is Prostate Cancer Screening Truly Harmful?

May 30, 2012• 7

By Peter Ubel

Dr. Timothy Wilt, a member of the United States Preventive Services Task Force, stood in front of the American Urological Association audience and explained why the task force could not recommend that men undergo routine PSA screening. At most, he explained, the test had been shown to benefit one out of 1000 men. Meanwhile, the test would cause hundreds of men to experience anxiety, and scores of them to experience impotence and incontinence from unnecessary treatments.

Twenty minutes later, I stood behind the same podium and asked the audience members to raise their hands if they disagreed with the task force’s conclusion. Ninety percent expressed their skepticism. What happened in the time between Wilt’s presentation and mine reveals a great deal about why experts cannot agree whether screening tests, like the PSA in middle-age men or mammograms in 40-year-old women, bring more benefit than harm, and about what psychological forces impede our ability, as a society, to figure out what basic bundle of healthcare services all insurance companies ought to pay for.

Wilt’s presentation was a model of scientific clarity. He explained that only two randomized clinical trials were conducted with enough scientific rigor to provide useful estimates of whether the PSA test saves lives. One trial showed no benefit and the other revealed the one in 1000 number which the task force took as the best case scenario. Wilt was followed on stage by Ruth Etzioni, a biostatistician at the Fred Hutchinson Cancer Research Center in Seattle. Etzioni presented a statistical model suggesting that the PSA test benefited many more than one in 1000 men.

How Much Weight Should Anecdotes Really Have In Health Policy?

May 23, 2012

By D. Brad Wright

There’s something compelling about the personal narrative that vast mountains of quantitative data cannot rival. Anecdotes are, quite simply, powerful. They tap into our shared humanity, making something seem somehow more real by putting a face on it. This is why, if you follow politics for very long, you will find numerous cases of policymakers championing issues that have touched their own lives in some way. For example, Senator X doesn’t care about issue Y, until they discover that their son or daughter is affected by it. Then, almost overnight, they seem to care more about issue Y than almost anything else. Such a shift is completely understandable, but often out of proportion to the true scale of the issue in society.

In health policy, the personal narrative can also be very powerful. In fact, the journal Health Affairs routinely runs a “Narrative Matters” section that puts a face on the health care issues of the day. It is absolutely critical that health policymakers, health services researchers, and others, not lose sight of the fact that their work and the subsequent decisions it informs, are based on real people. However, it is equally critical for objectivity to be maintained, and narrative can threaten our work in this regard.