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    Old 03-06-2009, 03:50 PM   #1
    IADT3since2000
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    Talking Screening for prostate cancer - why it's wise

    ACE28 recently raised the question whether screening for prostate cancer was wise on another thread. This question has affected so many of us and will affect many others, so here it is in its own thread. You can read his post on the thread "Considering Active Surveillance for low risk cases", but here is a pertinent excerpt. I'm inserting some thoughts and facts in green. Jim


    Quote:
    Originally Posted by ACE28 View Post
    ... My MD did not test my PSA during my last physical and many patients are being advised to discuss the test with their doctors, both the pros and cons.

    I see it that way too: a consensus or at least large number of physicians and some of their associations who think that screening is controversial and best presented to patients by offering it but discussing pros and cons.

    Some well-known, highly respected experts have even advised against screening. The doctor in the vanguard is Dr. Thomas Stamey of Stanford, famous for his PSA research and work as a doctor. He is so concerned that prostate cancer is overtreated that, on balancing benefits and costs, he feels men should not be screened for prostate cancer: just wait for those men who develop symptoms to show up at their doctors' offices and treat them at that time. That avoids all the anxieties, effort and cost that go with PSA tests, Digital Rectal Exams (DREs), and biopsies, which often trigger false alarms.

    Of course it also means that those of us who do develop prostate cancer will not get treatment until symptoms develop, and at that point the cancer is almost always incurable and far advanced.

    I try to view the issue objectively, but I would be considered biased because I'm surely one of those guys who would have had a well advanced, probably deadly case, except for the warning I got from a PSA test. At age 56, in for a routine physical, my doctor concluded my exam by telling me I was fine. I asked if I shouldn't have a PSA test, and he said he did not think it was necessary. (By the way, only a half hour before I had written on my history chart that my father had died of prostate cancer in his eighties.) His response surprised me, but I too had heard some experts advise against the test, and for a moment I weighed whether I should insist. I'm glad I did. That doctor was some kind of embarrassed when my test came back at 113.6 a few days later! Thanks to the warning (better late than never), to some really good doctors and advances in managing and treating the disease, and probably to prayer, I'm doing well today with incurable but hopefully chronic and not lethal prostate cancer.


    The latest PSA research appears to be conflicting and discrediting the older studies.

    News accounts are so often off the mark when it comes to prostate cancer. At least you know that something has happened, but you need to look into it with thought and some knowledge. Unfortunately, a lot of the public is not in the habit of doing that.

    Also, some of the highly touted studies are just deeply flawed, sometimes despite the best efforts of the researchers acting on what was known when the study started. A key example is the Swedish study on surgery versus "watchful waiting" that has resulted in two key papers, with Holmberg and Ben-axelson as the lead authors of each. In essence, one key problem was that many of the watchful waiting patients had cancer that would now be seen as clearly aggressive and a bad fit for a watchful waiting approach. I've talked to a number of doctors about that. Some see the problem and issue clearly. Others don't; they sometimes say that we need to use those studies because they are "the best we've got."


    Once again the latest news continues to leave many bewildered. One recent article I read from Dr.Schaeffer at the Baltimore study for aging mentions that
    PSA screening can find cancers that may become life-threatening in 5 to 25 years, there has been increased usage of the test in 40 to 50-year-olds. But the test can also discover cancers that never become life-threatening, perhaps in up to 30% of the cases.

    I believe the evidence from many studies is convincing that many prostate cancers discovered by screening are likely to be not life-threatening and not even life-inconveniencing. I haven't tried to figure out the percentage, but I'm confident it is substantial. But here is the critical problem: as of March 2009, medical science is unable to determine for certain which cancers will be dangerous and deadly and which will be harmless. Many screeing detected cancers will be at least dangerous if left untreated, and they won't be treated unless they are detected. If you do not screen, you are unlikely to detect tese cancers.

    I'm convinced that for 2009 the best approach is screening plus use of many clues now available to decide whether treatment or active surveillance, the subject of another recent thread, is best.

    Here's a thought: if a man knows he would not be able to withstand his abhorrence, his recoiling from the knowledge of having biopsy-proven prostate cancer, even if he knows there is a strong chance it is mild, probably harmless case, and if his risk at the time of the screening decision appears low (age, race, family history, nutrition, lifestyle plus new genetic and other clues we may soon have), maybe he should not be screened. That way he would avoid unnecessary treatment, and his risk of developing serious prostate cancer would be lower than average, though still a real possibility.

    On the other hand, if a man believes he can make a good choice whether to have treatment or not, based on all the facts, choosing active surveillance if that is a sound option in his case, then what has he got to lose from screening?

    Also, once a man realizes his PSA has risen a bit, he may be a lot more motivated to try some of the nutritional and lifestyle tactics, also perhaps including mild medications such as finasteride, Avodart and a statin drug. Those alone may be enough to control or even cure a mild case. He may be able to head off the need for a biopsy and for treatment.


    Many men who are older than 75 undergo continued PSA screening, potentially leading to unnecessary treatment since death from other causes is more likely than death from prostate cancer.

    I like my line of thought in the preceding paragraph, at least for fairly healthy men older than 75. Again, I'm a bit biased as both my father and his father, my grandfather, were diagnosed with prostate cancer in their seventies and died of it in their eighties. I'm positive that both would have liked to have had earlier warning and to have been able to take advantage of the great treatment advances that have occured in the past two decades.

    For older men, life expectancy and other health conditions should be a lot more prominent in decisions about prostate cancer treatment. Active surveillance should be a much more prominent option, even if the cases have some elements that are not low risk. (I'm a layman with no enrolled medical education, but I've heard experts advocate that, and it makes excellent sense to me.) But for some men older than 75, I'm convinced that at least one of the many treatment options will make sense. At that age, surgery would be an unlikely choice - almost ruled out, but there are a number of other typically acceptable options.

    I guess I just don't like that ostritch strategy!



    The optimal approach to prostate cancer screening remains controversial.

    I'm totally convinced that there is controversy. I'm also convinced there should not be controversy!

    Here is another consideration that looks vital to me: since key research papers were published in 2004 and 2005 by the team led by highly respected prostate cancer researcher Dr. Anthony D'Amico, MD, we have known that a PSA increase at an annual rate of more than 2.0 in the year prior to diagnosis is another, independent key clue in predicting the seriousness (or not) of the case. If a man does not have an annual PSA test, he and his doctors will not have this vital clue!

    This clue is so important because it illuminates the big three pieces of information we often use to assess seriousness: the stage, the PSA level, and the Gleason score, whose importance is illustrated by their role as the constituents of the Partin Tables, used to estimate the likely success of local therapies. A PSA velocity higher than 2.0 fairly strongly suggests that the case is substantially more serious than indicated by the big three, especially if the cancer can be felt (Stage 2 or higher). On the other hand, a PSA velocity of 2.0 or lower, especially much lower, is a pretty good indicator of a case that will likely be milder than indicated by the stage, PSA level and Gleason.

    We aren't talking subtleties here. For instance, "[We found] that within seven years after radical prostatectomy, depending on the clinical tumor stage, Gleason score, and PSA level at diagnosis, up to 28 percent of men with an annual PSA velocity of 2.0 ng per milliliter died of prostate cancer despite undergoing radical prostatectomy." (p. 132, D'Amico, 2004) (Details in Figure 2, p. 133, included (my eyes viewing graph), for these patients with a PSA velocity of greater than 2.0 in the year before diagnosis, a death rate of about 32% for stage 2 patients at about 10 years, about a 28% death rate for patients with initial PSAs greater than 10 at around 9 years, roughly a 35% death rate for Gleason 7 patients at around 9 years, and about a 58% death rate for Gleason 8 to 10 patients at 7 years (and thankfully flat - no more deaths, through 10 years). These rates are far higher than what we would otherwise expect from just looking at stage, PSA and Gleason. (We do need to keep in mind that this information is not a curse but a caution; those of us with advanced cases (like me) need to realize we need to do more to control the cancer. Fortunately, great advances mean we can do more!

    To highlight how independent of other factors this D'Amico researched factor is, consider that "Fifty percent of the patients with a PSA velocity of more than 2.0 ng per milliliter had a PSA level of 10.0 ng per milliliter or less, a clinical stage of T1c, and a Gleason score of 6 or less at diagnosis." (page 131, D'Amico, 2004) In other words, fifty percent of the cases we now see have higher risk looked like low-risk patients! You would just not be able to see whether a patient had that risk unless he was screened annually with a PSA test.

    I would really like to know why those doctors who oppose or are lukewarm toward screening think we do not need that clue. I could understand that view before 2004/2005, but not now. My suspicion is that they are not aware of the research by the D'Amico team. If you should develop prostate cancer, would you be comfortable with navigating your choices without that vital clue whether your PSA velocity was more than 2.0?

    It does make sense, based on research, for men with very low PSAs to get PSA tests every other year. I don't recall exactly where it's safe to decide to skip a year, but I have a hunch it is around a PSA of 1.0 or lower. While patients who skip a year might miss out on the D'Amico clue (unless an approximation could be made based on their known scores), the chance that the PSA will suddenly and sharply rise is very small. Now that is an reasonable issue for discussion with pros and cons, to my eyes!



    To date, there is limited evidence from which to inform the decision on when to discontinue prostate cancer screening

    To me, the limitation is not in the evidence but in the thinking, and our media and conventional wisdom experts have not helped us much.

    I hope my tone does not put off discussion and expression of other viewpoints. I just feel so strongly about the wisdom of screening that I express it with emphasis. I realize that I may have missed something. I really do hope we will have a discussion. I'm sure those of us who favor screening, probably most of us on this board, would welcome questions.

    Jim


    Last edited by IADT3since2000; 03-06-2009 at 03:54 PM. Reason: Added paragraph about motivation for nutrition, lifestyle and mild drugs.

     
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    Old 03-06-2009, 05:44 PM   #2
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    Re: Screening for prostate cancer - why it's wise

    Jim- your incredibly learned comments are very well presented as always. I actually think a compilation of your posts would make for a great book, something like "essays on prostate cancer detection and treatment."

    You know from my earlier posts that I'm in favor of the testing and screening. Those who are 50 years old, while unlikely to have a troubling PSA or trend, are exactly the ones who probably need testing, since one could have a very aggressive case that really needs immediate treatment. I cannot understand why one would not want to be alerted, even if it means a biopsy.

    I'm pleased that my internist wanted me to get a follow-up PSA test three months after my rate of increase seemed out of line (even though my PSA was still below 4.0). I was mildly concerned when the retest was a little higher, although not by a lot, and I needed a biopsy. Even then, I was told (based on my age, free PSA, PSA) that the likelihood was 70% there would be no diagnosis of cancer-- but surprise, it was a Gleason 3+4, even though only one of 12 cores tested positive.

    So would I have wanted a "no-testing" doctor giving my my annual physical-- no way. With the many treatment alternatives out there and all the advances over the years, this disease is quite treatable.

     
    Old 03-06-2009, 06:17 PM   #3
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    Thumbs up Re: Screening for prostate cancer - why it's wise

    I'm with you on this one, Jim. Maybe part of the reason is that I (like you) would have benefited greatly from an earlier PSA test. When I turned 50, I decided to go get a thorough physcial exam at one of the major hospitals in Taiwan. That's where a DRE and PSA test turned up positive. (66.04) Up till then, I was pretty much asymptiomatic. (Looking back, I had symptoms, but they developed so gradually over the years that I guess I slowly got used to them. Figured they were part of the aging process. Does that make sense?) So I wish I'd gone in earlier for a PSA test. And I actively encourage other men to do that now.

    I agree that there are some issues that arise out of a rush to possibly unecessary treatment, but I think the responsibility for correcting these issues lies mainly with the medical community. Of course, we patients need to be educated and proactive with these things, but most of us aren't. We don't know enough (until it's too late) and pretty much follow our doctor's advice without question. It seems to me that educating the medical community on the necessity of PSA testing - while understanding the need for great caution in jumping directly into radical treatment - is the way to go. Turning the public and doctors against such testing is just too dangerous. I mean, compare the worst that can happen if PSA tests lead to unwarranted treatment with the worst that can happen if men don't get tested and wind up with advanced prostate cancer. (Unnecessary, expensive, and debilitating results versus unnecessary death.) Of course, I don't think we have to settle for either.

    Sorry to ramble. I guess I must feel strongly about this one, too.

    Gregg

     
    Old 03-06-2009, 06:49 PM   #4
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    Re: Screening for prostate cancer - why it's wise

    Hi IADT..

    You really enlightened me with such a well thought out and elaborate description of the PSA screening and some of the latest research.

    I wasn't so much stating whether it is wise. I was just mentioning my confusion about the lack of emphasis which is now being placed on many screening tests which were considered very important up until recently.
    I question how much of the statistical information we read about is either slanted or reported inaccurately. I have a strong feeling of distrust.
    When my doctor performed my last laundry list of blood tests, the PSA was not mentioned. He also did not perform a Homocysteine test because of the latest inconclusive results with that test. By all means, I would like to have been tested regardless of his negativity, but he is the doctor with the "latest information". On a personal note, I tend to believe that many research studies are funded by Insurance companies and Pharmaceutical companies. If Pfizer cannot design a pill (that can pass FDA requrements) to raise your good HDL cholesterol, they will provide funding to discredit the HDL studies. When a supplement such as Niacin can improve your entire blood lipid panel for less than 10 cents a day you can imagine how the drug companies feel. My doctor thinks I'm crazy for taking vitamin supplements (with the exception of Vitamin D which he had me tested for several months ago) He strongly stressed the importance of this vitamin for the regulation of calcium and for heart health. Oddly my vitamin D was slightly deficient, even though I eat well and seem to get enough sun. He is a cardiologist and stressed the importance of this vitamin for heart health. Bottom line is doctors practice medicine and most are not alternative or holistic doctors. If Insurance companies have to pay for 1,000 screening tests a day with the majority of results being either inconclusive, negative and perhaps 300 tests may require additional testing, and these tests may include invasive In-patient medical proceedures with risks to the patient, to perhaps save 2 lives over X amount of years. These expenses are being incurred primarily on the basis of the lab PSA test. To many doctors and Insurance companies this is unacceptable. This is the way the Insurance companies tend to view every medical alternative. Unfortunately there are also very unethical doctors who love to over-treat and cause anxiety and needless concern. Why? For money and additional referrals. I think these are some of the reasons why the PSA test has been coming under fire recently. Alternatively, (regardless of the PSA test controversy) the PSA test has proven to be a godsend for those who were identified rather accurately and able to be treated effectively.

    I am in total agreement with the benefits and advantages of the PSA screening test at periodic intervals. That is why for the 10 + past years, I was screened at least once a year. The test is fairly cheap and can help discover a more serious condition brewing. It appears that Insurance companies are now mandating the frequency of many screening tests including Colonoscopies and Upper GI series. The colonoscopy screening interval was once every 3 or 4 years, this has changed to about 7 to 10 years in the majority of patients. Whether this will equate to proper medical judgment is still very questionable, but it saves money. The business of Medicine is forever changing.

     
    Old 03-07-2009, 03:28 PM   #5
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    Re: Screening for prostate cancer - why it's wise

    Quote:
    Originally Posted by daff View Post
    ...Even then, I was told (based on my age, free PSA, PSA) that the likelihood was 70% there would be no diagnosis of cancer-- but surprise, it was a Gleason 3+4, even though only one of 12 cores tested positive.

    So would I have wanted a "no-testing" doctor giving my my annual physical-- no way. With the many treatment alternatives out there and all the advances over the years, this disease is quite treatable.
    Hi daff,

    Again thanks for your very kind and encouraging words! But I think I'll leave the publishing, at least for now, to the physicians I so admire, men like Dr. Myers and Dr. Strum. I'm really following in their footsteps, or trying to, and I'm in awe of the superb job they do in getting out key information.

    About your diagnosis: whew! That was close! If that one biopsy core had been placed elsewhere, you might not have known of that aggressive cancer until much later! Your story made me think of how close I came when the doctor told me he did not think a PSA was necessary, and I actually thought about it for a moment, even though I wanted to touch that base, and then the result was a PSA of 113.6. For most of us the diagnosis is fairly routine and the case turns out to be routine, but quite a few of us, like you and me, have that near miss experience. Let's hope that's a one time thing! Routine is nice.

    Jim

     
    Old 03-07-2009, 03:43 PM   #6
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    Re: Screening for prostate cancer - why it's wise

    Hi Gregg,

    I think your whole post is right on the money and not at all rambling.

    The excerpt above reminds me so much of my own experience.

    Jim

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    Old 03-07-2009, 03:48 PM   #7
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    Re: Screening for prostate cancer - why it's wise

    Hi again Ace,

    You make a lot of good points and describe the experience so many of us feel as we face the medical world.

    Vitamin D is turning out to be a major player on the health scene. A lot of us do not make much of it as we get older, and we get little from the sun via our skin during the colder months. There is a ton of recent research on vitamin D. It's looking like a vitally important supplement. I was amazed at what I found about it on [url]www.pubmed.gov[/url].

    Jim

     
    Old 03-08-2009, 10:27 AM   #8
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    Re: Screening for prostate cancer - why it's wise

    Quote:
    Originally Posted by IADT3since2000 View Post
    ...
    About your diagnosis: whew! That was close! If that one biopsy core had been placed elsewhere, you might not have known of that aggressive cancer until much later!
    ...
    Jim- What's interesting is that I never really focused on that fact-- that I was actually lucky that they found it in my first biopsy of 12 cores. Guess I'd been taking that part for granted, but if they had taken a sample of 8 or 10, who knows if they would have discovered the cancer. Then, by the time of my next PSA, it probably would have led to another biopsy, but the cancer would have had those extra months to spread. While not the subject of this post, the number of cores taken in a biopsy should be a minimum of 12, and knowing what I do now, I'd probably have opted for, or insisted on, a greater number than that. There are probably some old-fashioned docs that still only do 8....

     
    Old 03-08-2009, 01:57 PM   #9
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    Re: Screening for prostate cancer - why it's wise

    Quote:
    Originally Posted by IADT3since2000 View Post
    Hi again Ace,

    You make a lot of good points and describe the experience so many of us feel as we face the medical world.

    Vitamin D is turning out to be a major player on the health scene. A lot of us do not make much of it as we get older, and we get little from the sun via our skin during the colder months. There is a ton of recent research on vitamin D. It's looking like a vitally important supplement. I was amazed at what I found about it on [url]www.pubmed.gov[/url].

    Jim
    IADT - Vitamin D is the only vitamin my doctor was very adamant on having me tested for. When I mentioned taking Vitamin C, Magnesium and OMEGA3 fish oils, he felt that I was wasting my money. He said these vitamins are very important if you have a deficiency, and I don't have a deficiency. As far as OMEGA3 fish oil, he thinks it's a better idea to eat a fatty fish at least two times a week. He did prescribe an OMEGA3 fish oil called "LOVAZA" to help lower my triglycerides and assist the Niacin (NIACOR) that I am taking. These 2 supplements have made a world of difference to my Lipid panel. I will also continue the Vitamin D.

    P.S. Thanks for the information on the [url]www.pubmed[/url] information. VItamin D appears to be a vitamin that many are lacking and it may prove miraculous for many conditions......

     
    Old 03-08-2009, 02:10 PM   #10
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    Re: Screening for prostate cancer - why it's wise

    Quote:
    Originally Posted by yanick123 View Post
    I find troubleling that a Dr will want less informations in the fear of over treatments. I doubt that an annual check-up (PSA level and digital probing) take a big toll on health care unless insurance companies issued a memo to lower theirs cost.

    I think that Dr need more data so they can have a big picture of what is going on and active surveillance will give the doctor dept in their analysis with the history of the follow up. Otherwise you only get a too late end point. Prostate cancer is really a silence killer; you get visible symptoms want it is to late.


    I will turn 40 this year and will start my annual check-up so in ten years the doctor can see the big picture.

    For the vitamin D, you are on the money, itís the only vitamin supplement that show a big risk factor if you lack it. A recent study on the journal Endocrinology by Weigel at the Baylor College of Medicine, Houston, Texas even showed that vitamin D inhibits the proliferation .

    Yanick

    Hi Yanick123 - I was about 22 years old when a doctor began performing a DRE (rectal check). This doctor at the time believed that it was never to early to perform this test. This doctor was appointed by President Jimmy Carter for a governmental position due to his cancer expertise and research studies. Even though at that age I was scared to death to say the least when a doctor would probe me, I feel (at that time) the doctor was being cautious, and obviously he knew something that I didn't know. This helped prepare me for future physicals, and gave me a baseline to compare some future check-ups. The average age now I suppose is about 40 years old to begin screening. I think you are correct to begin the PSA screening this year.

     
    Old 03-10-2009, 06:24 AM   #11
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    Re: Screening for prostate cancer - why it's wise

    Quote:
    Originally Posted by yanick123 View Post
    Hi Ace28,

    Thanks for the advice on the screening. For the intake of Omega-3 the important is the proportion vs Omega -6. Omega-3 fat is an anti-inflammation agent whereas Omega-6 is a pro-inflammation agent. A balance diet is 4 part of Omega-6 for 1 part of Omega-3. Typical North American diet is 16 part of Omega-6 for 1 part of Omega-3. Let say this ratio products an inflammation environment that help cancer cells. We can also add 1 tsp of ground flaxseed on our cereal or yogurts in the morning to help restore the ratio in the Omega fat with your 2 fat fishes a week.

    Yanick
    Thanks yanick123,

    I think (unfortunately) most Americans consume too much OMEGA-6 in their daily diets. I don't place too much emphasis on these ratios, I just try to increase my fish and OMEGA3 daily intake. I also try not to exceed my daily fish intake. The problem (my doctor informed me) with OMEGA3-FISH oil is the effect it has on blood clotting factors. While that appears to be a positive factor for some, for others (including myself) it can cause easy nose bleeds, prolonged bleeding and gastro/rectal-bleeding.

     
    Old 03-12-2009, 05:40 AM   #12
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    Re: Screening for prostate cancer - why it's wise

    I feel compelled to write after just seeing a segment on the Today Show this morning- on should one test for cancer. Dr. Gilbert Welch (Dartmouth Medical School professor) who has just written a book on this subject was asked a question by Matt Lauer as to whether or not he should have his annual PSA test. The response was that it's a personal decision and it would take him 30 to 60 minutes to discuss the topic. He then said it's not been proven that PSA testing has led to any saved lives.

    Maybe he'll sell some books and maybe there's some other cancers that one might not need to test for, but I find it preposterous to say that waiting for a DRE to be the indicator for prostate cancer is the better way to go. I can't understand the implication that not one death has been prevented by one's having been alerted via the PSA test and of course, subsequent biopsy and treatment.

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    Old 03-12-2009, 05:30 PM   #13
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    Re: Screening for prostate cancer - why it's wise

    Quote:
    Originally Posted by daff View Post
    I feel compelled to write after just seeing a segment on the Today Show this morning- on should one test for cancer. Dr. Gilbert Welch (Dartmouth Medical School professor) who has just written a book on this subject was asked a question by Matt Lauer as to whether or not he should have his annual PSA test. The response was that it's a personal decision and it would take him 30 to 60 minutes to discuss the topic....
    Hi daff,

    So many of these doctors are generalists who do not closely follow developments in prostate cancer; that includes many doctors who appear on TV or contribute to newspaper reports. I would really like to know how many of those who are lukewarm or negative toward PSA screening are aware of (1) the D'Amico research on a rise in PSA of more than 2.0 in the year before diagnosis, and (2) the extent and success of active surveillance programs and confirmed guidance for low risk cases. My guess is that few of them are aware.

    I'm going to a meeting of the American Urological Association (AUA) on Monday in DC, and I believe the subjects will include screening guidelines. I'm hearing the AUA is about to launch a strong new guideline on screening.

    Jim

     
    Old 03-12-2009, 06:56 PM   #14
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    Re: Screening for prostate cancer - why it's wise

    Quote:
    Originally Posted by IADT3since2000 View Post
    Hi daff,

    So many of these doctors are generalists who do not closely follow developments in prostate cancer; that includes many doctors who appear on TV or contribute to newspaper reports. I would really like to know how many of those who are lukewarm or negative toward PSA screening are aware of (1) the D'Amico research on a rise in PSA of more than 2.0 in the year before diagnosis, and (2) the extent and success of active surveillance programs and confirmed guidance for low risk cases. My guess is that few of them are aware.

    I'm going to a meeting of the American Urological Association (AUA) on Monday in DC, and I believe the subjects will include screening guidelines. I'm hearing the AUA is about to launch a strong new guideline on screening.

    Jim
    Jim- Look forward to hearing about the meeting when you've returned. This particular doctor may or may not be aware of the details re: PSA testing, but he sure made it sound like he was an expert- telling Matt Lauer that he
    could have a one hour discussion on the subject. I think he's very interested in promoting his book, so taking controversial positions is good for that.

     
    Old 03-16-2009, 10:30 AM   #15
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    Re: Screening for prostate cancer - why it's wise

    Yanick123,

    Fish (Omega3's) are known to have a blood thinning effect. Other over the counters are Vitamin E, Garlic, Ginger, Ginkgo Biloba and Aspirin. I don't believe my Internist is talking from his hat. There are many alerts and warnings not to mix certain medications (especially Coumadin) with either of these supplements or take them together. Clotting factors need to be pretty precise for normal clotting. My sister began bruising (bleeding under the skin) because of Vitamin E and Fish oil taken together.. Aspirin appears to be the most potent. My dentist once told me that my bleeding was excessive and asked me if I take fish oil, vitamin E etc..... At that time I was also taking a baby aspirin (81mg a day). The combinations can be very dangerous if you are having a medical proceedure, or get a bleeding injury..

     
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