Where did Willy get this idea from?

It is the crossover moment. For the first time, more men are dying of prostate cancer than women are from breast cancer. Any GP surgery will offer a blood test to check a man’s prostate-specific antigen (PSA) indicating cancer. All men have to do is ask.

The trouble is that, as we all know, men are from Mars. They don’t go to GPs, don’t talk about illness and believe in their own invincibility. Men with their compartmentalised brains are inherently greater risk-takers and believe they will beat the odds. In any case, to concede the threat of illness is an acknowledgement of weakness – very unmasculine.

It doesn’t have to be about EQ/SQ you know. Could in fact be because we’ve been spending 9 x on trying to treat breast rather than prostate cancer.

28 comments on “Where did Willy get this idea from?

  1. I’ve discussed this with my GP and PSA isn’t a reliable indicator, too may false positives. Positive tests require a biopsy and those have significant risks.

    I have a mate who pays to get one every 3 months and keeps a graph going so he can look at long term trends.

  2. Your mate voluntarily undergoes 4 prostate biopsies a year???

    Won’t be long until there’s nothing left of it!

  3. The convention in recent times (from GPs) is ‘you don’t want to open that can of worms’, The test isn’t reliable and will unnecessarily worry you. To some extent this has been reinforced by American friends who have been encouraged to take a battery of tests, all of which turned up zilch, but earned the medics lots of dollars. Other friends believe I’m crazy to ignore it. Which I do.

  4. The absolute number of deaths is rather misleading. Prostate cancer has IIRC well over 90% 5-year survival, whereas breast is around 70%. Breast is usually detected at an earlier stage (to the extent you can compare between primary sites like this). Prostate like most internal cancers is rarely detected early, but it is usually not aggressive. Those early stages can be cured surgically.

    Ironically that stonkingly high survival makes it extremely hard to prove a treatment works.

  5. “Any GP surgery will offer a blood test … all men have to do is ask”

    Well, no. All they’ve got to do is get an appointment at a GP’s clinic at a time when it’s open and they’re not working (no sick leave for routine tests).

    Which is easy for a Guardian columnist, but rather trickier for for most men.

  6. Its all very good Tim running on about ” compartmentalised brains ” and all that.

    Its some black man shoving a finger up my arse which puts me off and all the conflicting stories of wether this actually works .

  7. Tick for RichardT – I had my PSA done, mid-week, mid morning. I’m under 67 but clearly too old to have school aged children. The nurse asked if I was between jobs which was exactly right.

  8. “But what if the whole intellectual edifice supporting these claims were wrong? Enter the scientist Cordelia Fine, whose Testosterone Rex, winner of the 2017 Royal Society prize for popular science writing, convincingly debunks the entire thesis.”

    Willy thinks Cordelia Fine is credible, thereby showing his ignorance.

    Here are a couple of reviews of Fine’s book by people who know what they’re talking about:

    http://quillette.com/2017/03/21/cordelia-fines-testosterone-rex-a-review/

    http://yeyoscorner.wordpress.com/2017/09/27/why-sexual-selection-matters-and-why-cordelia-fine-is-wrong/

  9. ‘Any GP surgery (sic) will offer a blood test to check a man’s prostate-specific antigen (PSA) indicating cancer. All men have to do is ask.’

    This is a false characterization.

    Should your PSA be elevated, the GP would have to refer you to a urologist. Urologists fail at the bioethical restriction, Primum non nocere. First, do no harm.

    GPs will try to talk you out of a PSA test, suggesting it could be harmful. Which is absurd, as it can be done any time blood is being checked anyway. There is double ought zero risk in the test. There is real hazard from the urologist should your PSA be elevated. But that risk is not in the test. Intelligent people – doctors (!) – don’t get the distinction.

    Additionally, an elevated PSA does not necessarily indicate cancer. Medical advise from Will Hutton.

  10. I’ve got the usual late-middle-age prostate expansion and had a PSA test about 2 years ago. It was elevated, saw the Urologist & then had a biopsy – not especially painful – which found a very small indication of cancer in one sample. So I’m now on periodic PSA tests, currently with no upward trend and I’m quite happy with that. I’m certainly not going to opt for surgery or radiotherapy at this stage. I think if it was the aggressive sort, like that which killed Frank Zappa, then I would be experiencing something rather nastier by now.

  11. What’s the average age of both groups? If it’s 75 for men but 55 for women it doesn’t sound like men are getting seen off. I thought most old men (80+?) had prostate cancer, it’s just that something else usually kills them first.

  12. Willie got to the same point eventually… though a different multiple than tim’s.

    “What is driving men’s mortality rate from prostate cancer is not masculine brain structures – it’s the NHS spending half as much money on communication and treatment as it does for breast cancer”

  13. A couple of points:

    – I’ve had PSA test for the last 5/6 years (which was getting lower!) but was recently told by a new GP that as I’m 67 they don’t do them anymore for my age group. Anyone else had this ‘treatment’?

    – One of my friends has had a (very) high PSA score, biopsy etc which showed indications of cancer, and is on the NHS pilot programme for prostate cancer, which gives 3 options:

    – surgery
    – drugs
    – do nothing.

    He chose the do nothing route. He has PSA tests etc every 3 months under strictly controlled conditions (same place, same nurse etc) and 3 years later and many tests all remains the same. No problems & thus no surgery etc.

  14. Richard Lehman’s BMJ blog, July 2017.

    “Watching for 12-20 years equals surgery for early prostate cancer

    In the early era of prostate specific antigen testing, from 1994-2002, 731 men with localized prostate cancer (mean age, 67 years; median PSA value, 7.8 ng per milliliter) were randomised to radical prostatectomy or observation. The Prostate Cancer Intervention versus Observation Trial (PIVOT) is a rare example of the right trial done at the right time. Now we have the results from a median 12.7 years of follow up, and all-cause mortality is the same in both groups. “Urinary incontinence and erectile and sexual dysfunction were each greater with surgery than with observation through 10 years. Disease-related or treatment-related limitations in activities of daily living were greater with surgery than with observation through 2 years.” It may be that surgery confers a small overall benefit if the starting PSA is over 10. But we shouldn’t pay attention to post-hoc analyses that can’t be tested: the default option for localized PSA-detected cancer is clearly to watch and wait, unless the patient chooses otherwise. Best of all, avoid doing PSA tests under most circumstances.”

  15. The same blog on 17/10/16

    “NEJM 13 Oct 2016 Vol 375
    Outcomes and choices
    This week’s print NEJM contains mostly papers I’ve already commented on—notably, Gilbert Welch’s important study of mammography and breast cancer outcomes and the landmark British trial comparing surgery, radiotherapy, and watchful waiting for PSA detected prostate cancer (ProtecT).

    However, I hadn’t commented on the patient reported outcomes paper that went with this study. This is immensely important because the two papers together provide all the information that men with localised prostate cancer detected by PSA need to make a decision about treatment. If they opt for surgery, they run the highest risk for impotence and urinary incontinence, and this is unlikely to improve over time. If they opt for radical radiotherapy, they run similar risks but the effects tend to improve after six months. They are also likely to have bowel effects, which may resolve to a varying extent. Interestingly, no significant differences were observed among the groups in measures of anxiety, depression, or general health related or cancer related quality of life. In reality, I suspect that few men will now opt for anything but watchful waiting, but at least they should have these choices put clearly before them.”

  16. Our medicare system here in Calgary, Canada made an attempt a few years ago to get a large sample size to test the usefulness of the PSA. They asked for, and got, tens of thousands of men aged 40 plus to volunteer to take the test.

    The idea was to follow them for the following 30-40 years and see if the testing was any help at predicting cancer. Following should be easy with a centralized medicare record keeping system.

    But, ha, ha, ha, it’s run by the government.

  17. I have a rising psa, now 19.8. I have no symptoms, and two biopsies, an MRI scan and the PCA3 test have not revealed anything. Next stop is a saturation biopsy, apparently. Any thoughts/advice?

  18. It’s been known for a long time that PSA was at best an indicator that it might be a good idea to have a deeper look.

    If a problem is found, then tracking pSA – looking for sudden spikes – on perhaps a yearly basis is cheap and non-invasive (just another of the tests done at an annual checkup).

    Luckily, there are now more sensitive tests – one a urine test can indicate cancerous cells in the urine; the other is an MRI of the prostate, something which for some god-forsaken reason has only just been introduced. If the urin test shows positive, one thinks hard about having an MRI.

    If the MRI shows identifiable areas, a targeted biopsy in that area can produce testable cells to provide better advice on what to do.

    I’ve had high and variable PSA results for a looooong time. I’ve decided that I just have a snowflake prostate – damned thing gets upset every now and then, and PSA goes up.

    There’s a prostate-shrinking drug (Avodart in the USA), which had no apparent side effects and worked for me, and after that the thing seems to stay reduced in size long term – no more getting up at night and finding it difficult to pee.

  19. There are lies damn lies and statistics taken out of context- While many men die with prostate cancer ‘most’ prostate cancer is slow growing and compatively few men die from it – which is why in many cases not operating / or minimally invasive treatments/ waiting is the correct thing to do -heart disease, dementia or respiratory disease.
    About 1 man in 7 will be diagnosed with prostate cancer during his lifetime, but only 1 man in 39 will die from it. About 80 percent of men who reach age 80 have prostate cancer cells in their prostate Breast cancer on the other can be fast growing, is quite lethal and affects a large number of women and some men at a much earlier age.

  20. My GP had no information about prostate cancer. No leaflets, no posters on the wall. When I ask about things I should be worried about, his response was “You don’t need to worry about that”. In short he wasn’t prepared to even discuss any male related health issues. In short his attitudes was “man-up”.

    Don’t forget, men are not allowed to get ill. Any man complaining of being ill is behaving like a baby: it’s just “manflu”.

  21. Theo: My urologist says the thing about PSA is to look for a trend upwards as an indicator of things deteriorating. A bloated prostate is going to generate elevated PSA anyway. Mine isn’t too big, though the practice nurse who did my ultrasound scan before the up-the-bum biopsy said she had come across one 30cm diameter! I had a MRI earlier in 2017 with the brand new machine they had just installed, but it didn’t spot anything. The subsequent perineal biopsy did confirm cancerous cells spotted in the earlier one.
    Talk to your urologist & good luck with the saturation biopsy if you decide to have one.

  22. Not sure if things have changed with GPs but back when I lived in the UK it was nigh on impossible to get an appointment if you were a man. Firstly the surgery was only open during working hours so, if it was routine, you had to take time off work to go there. And secondly getting a booking if you were actually sick was a matter of negotiating with the anti-male harpies behind reception for a time slot about a week away.

    It ended up getting so ridiculous that my wife would call for an appointment for herself (which she would get for the same day), and then I would show up in her place. Reception would complain but I would say something about her feeling all right now and I didn’t want to waste the appointment!

    The NZ system is great in comparison. I pay to see my GP; I can get an appointment within 2 hours of calling or can pop in and wait if I want. They are open from 7am to 9pm Monday to Friday and 8am to 1pm Saturday and Sunday. If I need to see them outside of these times then they have a deal with a 24 hour clinic up the road which gets me a discount and that clinic has full access to my medical files.

  23. The NHS! It’s the envy of the fucking world. A GP’s appointment to get routine bloodwork done? For fuck’s sake. Here in the benighted tropics, I had a PSA test done by wandering into a clinic in the mall, having some blood drawn, and paying them £9 cash. Total time required: about four minutes. I got the results back by email from the lab after lunch the same day. Apparently my PSA level was 1ng/ml, so I’m not going to bother having another one for a couple of years. The whole thing was so cheap I decided to get my blood typed as well. That turned out to be more significant than the PSA test as only 4% of people here have my blood group. Only £9 for that test, as well.

  24. As a prostate cancer survivor, I have looked at the whole process in some detail, even reading relevant material from medical journals. First, the PSA test–in the words of its discoverer–is not fit for purpose. Fine if you have a low one (I did, by the way, a little above what it should have been) but a can of worms if you have an elevated one.

    The next step is the biopsy. I was offered an antibiotic even before the procedure–tells you something about the process! I had to have a full course of antibiotics afterwards.

    Then I had a positive result from the biopsy. (For those who are interest a T2B tumour.[Scale is T0 to T4]) So what do you do? Radiotherapy is one option, surgery another, active monitoring the third. (There are various experimental treatments out there. Questionable whether you want these, but might work.)

    These are “traditional” cancer treatments. Chemotherapy is a possible, last defence, option for metastatic cancer–not for the confined sort.

    I opted for surgery (it has immediate upfront impact, but good recovery potential, plus, if it does not do the job, you can have salvage radiotherapy–you can’t do the reverse.)
    No treatment is without consequences.

    Should you test? Depends on age, your history, risk appetite, concern about consequences. Basically, you are much more likely to have PCa if you are older. It makes a lot less sense for treatment then, given you can harbour it and it has very little impact on your life thereafter. It is an infrequent consequence of death compared to other cancers, heart and stroke, etc.

    In terms of dealing with the disease, you should know that the biggest study on screening and treatment found very little positive gains from this, but a potential for a lot of harm (basically, men being treated unnecessarily, with consequent adverse side effects).

    So it is a bit of a lottery where the value of the treatment works against you.

    Why then did I have surgery? It was an age thing. I was diagnosed as a result of being part of the large-scale study on this when I was 54. The likelihood of PCa becoming a problem in my late 60s or 70s was therefore very high. If I had been in my late 60s or 70s, I would have ignored the need for treatment.

    So the “challenges” for the healthcare system in finding and treating some but not all (to minimise unnecessary harm) is ongoing and, as far as I know since I have backed off from following medical developments in this field, still not getting the balance between treatment and non-treatment right.

    Hence, for a GP to advise against opening the PSA can of worms is not bad or neglectful advice.

    There is some hope on diagnosis, by the way, in a more discerning test than PSA. But I think this is some years away.

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