This article caught my eye because of a story a week or so ago about the GPs in the U.K. and Australia coming out against PSAs and rectal exams in the 40-year-old male. Same old argument…the likelihood of finding a cancer is low, too many men treated, costs, wouldn’t have made a difference etc etc blah blah blah. For this to really interesting to you, you have to know the most common mindset and personality of the average pathologist. Do you know one? Well as a rule they are quite folks. They rarely interact with the person of which the tissue they examine comes from. Don’t get me wrong. I love pathologists, but all the patient interaction stuff they don’t have to do. That’s why the chose pathology, they did not want to do all that patient care stuff. I get it. I chose urology because I did not want to go in at night for emergencies night after night. This is not a criticism.
When I had my biopsy done by my partner, I took the tissue to a friend who was a pathologist at our hospital. I did not think about it but I am sure he did…that he’d have to tell me the results. You see, they don’t do that. They read the tissue in the confines of their quite dark little office, dictate a report and send it off to the performing M.D. for him to break the news to that unfortunate patient. Clean, sterile and separate from the mess of the disease, treatment or aftermath. We don’t “shoot the messenger.” It was funny thing me trying to get an answer from the pathologist that did my biopsy. I wanted to know the next day. I called him and he said, “John, I am going to a satellite office this morning. It will be after 2 before I’ll have a chance to look at it.” My theory is that he had the diagnosis, but did not want to tell me. I remember the day distincly. I saw patient all morning, skipped lunch because I had the most intense butterflies imaginable and went swimming. The best most intense day of swimming I have ever had. When I finished swimming I decided to walk up to the pathology office to see if my friend was in and if he had the report. I speak to the receptionist and ask if Dr. So and So is in and she tells me to wait a minute. I wait about five minutes and out comes my friend. He did not look good. He looked very uncomfortable. I followed him to his office.
“John, I have bad news. We found cancer.”
“What is the Gleason’s score? What is the volume? Is it bilateral?” I hit him with a stacatto of questions that veered out of pathology and into clinical and again he became very uncomfortable.
Anyway…pathologists look at tissue and issue a report. Is tit he bad kind or the good kind… they know. They know how many specimens they get pertaining to prostate cancer. They know the ages of the patients of the specimens. They know if they are seeing a trend of more aggressive cancers in younger patients. They very may well be better in touch with the disease and its prevalence than the very GPs that are managing the patients. Remember, the GP sees a high PSA and then refers to the urologist and the urologist does the biopsy and the treatment recommendations. Maybe this is the rub!
So why have all of a sudden are their pathologist in Australia getting involved with this old argument. Maybe like urologists they are seeing the disease in its aggressive form much more frequently in the younger age group. Remember they are the ones who make the diagnosis and see it day in and day out. Why them and not the GPs? I don’t know, does the government had something to do with this? Will it increase the work load of the doctors like the GPs who are on the front line? Something is odd about all the government related heath providers the first to say don’t do PSAs on the younger male and that the PSA is a “harmful” test.
Be sure to note that they reference good ole Dr. Albin. See my letter to the editor about him under the author page of this blog (verdy interestingggg…as Shultz would say on Hogan’s Heros.)
Finally, what is clinically significant prostate cancer? Well, it is true that 70 % of men who are 70 and have an autopsy of their prostate will have prostate cancer. But is that clinically significant? I mean if they had had a biopsy would the volume of disease been enough to detect with just 12 small vermicelli sized cores? So at autopsy (often used as an argument against treating prostate cancer) prostate cancer is not the same as that found on biopsy. This doesn’t even take into consideration the Gleason score which is really the issue with treatment decisions.
I am quite pleased that the pathologists of Australia have taken this stand. It is admirable, courageous and so out of character. My point is that is if a group of pathologists found fault with limiting PSAs in 40 year olds and have spoken up about it, then they feel strongly about this issue. They are seeing the real “tea leaves” of this issue and its the prostate cancer specimen itself.
Pathologists urge earlier tests for prostate cancer
AUSTRALIAN pathologists will recommend that men who want to be tested for prostate cancer should do so from as early as 40, further igniting debate on the controversial test that critics say does more harm than good.
The Royal College of Pathologists of Australasia will release a position statement today recommending that men who choose to assess their risk of prostate cancer should be offered a prostate specific antigen test and digital rectal examination from the age of 40.
Those found to have levels of PSA in their blood above the median should be tested annually, it says.
A high level of PSA can indicate a man might have prostate cancer but it cannot reliably show if that cancer will kill him prematurely, and treatment carries high risks of side effects such as erectile dysfunction and incontinence.
Since the introduction of PSA testing the rates of surgery and treatment have skyrocketed without a corresponding decrease in deaths. Last year the discoverer of the test, Richard Ablin, called it an unreliable ”public health disaster”.
The president of the pathologists’ college, Paul McKenzie, said its recommendation was intended only for men who had already decided on testing.
“It’s a pragmatic recommendation … to make sure the test is being used in the most appropriate and cost-effective way.”
He said research did not show doctors should recommend against testing patients.
Ken Sikaris, a co-author of the statement, said annual testing only for men with higher PSA levels would cut down on pointless tests and give peace of mind.
Extra tests for those with higher levels could indicate cancer risk and the possibility that the cancer was aggressive, he said.
The chief executive of the Prostate Cancer Foundation of Australia, Anthony Lowe, said it would consider changing its recommendation for testing from 50 to 40 in light of the statement. This would enable doctors to trace changes over time which could vary among individuals, Dr Lowe said.
But Chris Del Mar, a professor of public health at Bond University who co-wrote the Royal Australian College of General Practitioners’ recommendations against testing, was concerned the stance of the pathologists’ college could convince people screening was effective. He said prostate cancer was different to other cancers. “Most people who get it do not die from it.”
Bruce Armstrong, a professor of public health at the University of Sydney, said the position statement could mean ”open-sesame” on screening.
Pathologists were in an excellent position to comment on the interpretation of PSA tests but could not give expert recommendations on whether asymptomatic men should be tested.
“It is unfortunate that they have decided to express quite serious recommendations in that respect,” he said. But it had been left to medical bodies because the federal government had been too cautious to provide guidance.
Simon Chapman, a co-author of a book on prostate cancer testing, Let Sleeping Dogs Lie?, said: “There is a one in 50 chance that 10 years from now or later a random man who gets tested will be spared death … But there is a 49 in 50 chance he will have been treated unnecessarily.”
In NSW about 77 per cent of men who had a prostatectomy remained impotent three years later, he said. ‘Would I rather be alive or dead?’
HAYES VAN DER MEER was told he had prostate cancer on the same day his twin boys were born. He was 42 years old.
Six years later he is cancer free and believes a radical prostatectomy saved his life.
Mr van der Meer argues all men aged over 40 should be tested. “People think prostate cancer is an old man’s disease but you can hardly say 42 is old,” he said.
His cancer was discovered after a GP offered him a PSA test during an annual check-up, and while he waited two years before deciding on treatment, in the end it was an easy decision. “At the end of the day, would I rather be alive with incontinence or erectile problems or be dead?”
But he suffered no such side effects from his treatment, a fact he attributes to being still fit and young at the time of the operation.