Colonoscopy

[royoftherovers]

21 minutes ago, PCM said:

Thank you.

Very interesting to hear...

My PSA varies, I have also had a (clear) related MRI and two DRE's ( also clear).

The first DRE was with my GP. As my name was called out in the waiting room, the doctor appeared wearing a plastic apron and rubber gloves. I expect the other patients waiting all secretly thought, "rather him than me!".

The term Digital Rectum Examination (DRE) was not recognised immediatley by me--even tho` I had had several in my history. What my mind envisaged Piers was something akin to what Dr Bones (Startrek) wears around his neck and which my mind saw as a distinct improvement and a modern digital version of what I used to know as the "wet finger in the wind exercise."

Anyhow the good news is that mylast reading has fallen within the accepted range for someone my age.

Stay well and eat sensibly!

Imagine my dismay when GOOGLE explaind to me that nothing had changed !

[peniole]

Yup nothing high tech about it yet unfortunately. 👆

[Barry14UK]

Always reassuring to to get a clear report. 

It is true that although PSA tests are a better indicator of the presence of cancer after treatment (but even so by no means definitive), than an initial indicator of PCa, the test is cheap, much more than for example the PCA3 test which was not widely used, though used in conjunction with the PSA test it improved the result.  The DRE is something that should be done by the GP in any case along with taking blood for PSA but being done by a finger in the rectum, not all the Prostate is reachable so this is not a good test.  Genetic profiling may prove helpful but this has not been widely adopted yet it would seem.  So meanwhile, with 12,000+ men dying of cancer a year, the second largest cancer killer of men, it's not clear to me how you check every man who might or might not exhibit PCa symptoms..  You can't rely on a DRE which can be quite subjective.

Biopsy, particularly a Transperineal one following a multiparametric MRI and possible bone or PET scan and then appropriate treatment is going to be the way for men with significant cancer, but being  expensive really needs justification.  So men should not have unnecessary harm from treatment they don't need although they have scans and biopsy.  The problem is that with so many men wanting an initial PSA and treatment, regardless if they have any significant cancer, they may want treatment that is unnecessary.  Also, this is putting a severe strain on the NHS in terms of clinical time and cost.  Professor Mark Emberton, world renowned Focal Expert,  has expressed a view that found early, a number on men who want treatment but to avoid most severe side effects, might be suitable for one or more of several types of Focal treatment as an intermediate or final treatment.

I have also been persuaded to give a talks to students on this having had both Focal and Hadron therapy, the latter in Germany.

     

[peniole]

1 hour ago, Barry14UK said:

not all the Prostate is reachable so this is not a good test

You don't need to reach the whole prostate. The vast majority of prostate cancers originate in the peripheral zone (PZ in below image), that's what you can feel through the rectum. Also, with proper training it is anything but subjective. It's the difference between poking the muscle at the base of your thumb to poking your knuckle when it comes to hardness, rubbery vs hard. Not to mention smooth (normal) vs bumpy/craggy (not normal). That being said mutiparametric tests are being evaluated that include imaging (e.g.MRI) along with a cancer marker (blood) test. None have reached the numbers required for a solid conclusion.

Now the reason we worry about PZ cancers is that they do not have early warning signs. Hence, the need to screen. While the other zones are wrapped closer around the urethra, they will announce themselves earlier with symptoms similar to benign prostate hyperplasia (hard to start a stream, hard to stop, dribbling...etc.).

Bottom line, again pun not intended, don't ignore your DREs.

[peniole]

Decent prostate layman's guide from the NIH (American) https://www.cancer.gov/types/prostate/understanding-prostate-changes

[KentColin]

I had a colonoscopy 2 years ago to check the dreaded polyps and I was asked whether I wanted to watch on a screen which I did .It was fascinating and a new perspective on things so to speak.No problems found and Movicol  sure does work  !!

[Barry14UK]

3 hours ago, peniole said:

You don't need to reach the whole prostate. The vast majority of prostate cancers originate in the peripheral zone (PZ in below image), that's what you can feel through the rectum. Also, with proper training it is anything but subjective. It's the difference between poking the muscle at the base of your thumb to poking your knuckle when it comes to hardness, rubbery vs hard. Not to mention smooth (normal) vs bumpy/craggy (not normal). That being said mutiparametric tests are being evaluated that include imaging (e.g.MRI) along with a cancer marker (blood) test. None have reached the numbers required for a solid conclusion.

Now the reason we worry about PZ cancers is that they do not have early warning signs. Hence, the need to screen. While the other zones are wrapped closer around the urethra, they will announce themselves earlier with symptoms similar to benign prostate hyperplasia (hard to start a stream, hard to stop, dribbling...etc.).

Bottom line, again pun not intended, don't ignore your DREs.

You don't know whether there is cancer in the area that cannot be reached even if this is unlikely  but it can and does happen.  This is what they say about it on Prostate Cancer UK, the foremost PCa Charity in the UK whose guidance follows that provided by leading consultants. 

"The DRE is not a completely accurate test. Your doctor or nurse can’t feel the whole prostate. And a man with prostate cancer might have a prostate that feels normal Your doctor or nurse can’t feel the whole prostate. And a man with prostate cancer might have a prostate that feels normal."  https://prostatecanceruk.org/prostate-information/prostate-tests/digital-rectal-examination-dre

Furthermore,  there have been cases  posted in the Community of that Charity where the assessment of the GP and hospital Urologist has differed significantly, so this actually happens in the real world.

Also, take a look here where four studies are considered and conclusions made rather than the one on which latest UK recommendations were considered.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5985061/#:~:text=Diagnostic accuracy of DRE&text=This was calculated using Meta,89.5–91.8%)%2C respectively.

[Herbie]

A mate of mine recently had an elevated PSA result so had to go in for biopsy. They took 47 samples (which he has vowed never to have done again unless he gets a general anaesthetic) from various locations around the prostate and it was declared benign.

A couple of weeks ago we went to my brother in law's funeral.

Six months ago he had a bit of pain and difficulty urinating and after various tests he was diagnosed with prostate cancer. A cancer nodule broke off and travelled into the top half of his body, where the consultant said it basically 'exploded' and LED to heart attack, a couple of other secondary cancers and eventual death six months later.

I'm awaiting the results of my home PSA test that I took a couple of days ago.

[peniole]

See explanation above Barry. You'll notice I talked about the zones, and specifically mentioned the symptoms of cancer arising in those zones not detected by a DRE. The urethral symptoms will give warning. Your link says the same thing but with less of medical explanation.

Also, those cases of GP vs urologist, again see above when I said with proper training. I've had the misfortune of dealing with GPs who were as thick as a plank. A urologist would have proper training, one would hope.

Just an FYI there is no such thing as a 100% accurate test. You take the best combination of sensitivity, specificity, positive and negative predictive values that you can get.

For example, a PSA test was thought to be good enough until it turned out to be not sensitive enough (missing too many cases, i.e. false negatives), not specific enough (ejaculating, riding a bicycle, having a DRE or an infection are all things amongst a host of other non-cancer related things that can elevate your PSA, so massive over-diagnosis i.e. false positives), but good enough to follow a case post diagnosis/treatment after you have established a personalized baseline.

You see a screening test needs to be sensitive enough to catch most cases (notice I said most, not all), without over-diagnosing cases that don't need to be treated or non-cancer cases. The PSA failed on both accounts. Currently, the DRE is the only thing that even comes close to fitting that description until studies on the newer diagnostic modalities provide statistical evidence.

What you're quoting in that link sadly is medical legalese. They are covering their collective behinds as well as informing you, that a negative test does not mean you are cancer free, and if you read the whole thing, a positive test means we need to investigate further. It's the same warning on every single test. So if you do end up having cancer, "but the test was negative doc" "yeah, but we told you...". See where I'm going with this?

This is my bread and butter specialty. I'm an MD/PhD in oncological sciences, researching and teaching this stuff for a couple of decades plus. If you're wondering my subspeciality is actually colon cancer, it's what I researched/wrote my thesis and published quite a bit on. Feel free to ask questions.

[Barry14UK]

4 hours ago, Herbie said:

A mate of mine recently had an elevated PSA result so had to go in for biopsy. They took 47 samples (which he has vowed never to have done again unless he gets a general anaesthetic) from various locations around the prostate and it was declared benign.

A couple of weeks ago we went to my brother in law's funeral.

Six months ago he had a bit of pain and difficulty urinating and after various tests he was diagnosed with prostate cancer. A cancer nodule broke off and travelled into the top half of his body, where the consultant said it basically 'exploded' and led to heart attack, a couple of other secondary cancers and eventual death six months later.

I'm awaiting the results of my home PSA test that I took a couple of days ago.

Hi Herbs,

I am sorry that PCa was responsible for the loss of your BIL.  When this happens it certainly brings home what could happen to us males.  Home PSA kits serve a purpose but ideally NHS test at local surgery best as they generally use same lab.  Having said that, PSA can vary for a number of reasons and you shouldn't have s*x, ride a bicycle or do anything really energetic for 24 hours prior to taking the sample or avoid if you have a UTI.

47 cores sounds too many for the TRUS which I can tell you stings like being flicked by a rubber band when each sample is taken.  He probably had a Transperineal template which is better with less risk of infection, under a spinal block (Epidural)  instead of GA.  With fewer cores and fusion it can now be by deep sedation which I found OK if embarrassing! 

As regards spread, sometimes the cancer cells are in concentrations so small that they can sometimes cannot be seen as they set up home in bone or tissue.  They can also travel through the lymphatic system.  Occasionally, they can form a tumour even as far as the Brain. This is then Prostate Cancer of the Brain. There is a brilliant talk by Dr Eugene Kwon of Mayo who covers this on his talk about Oligo Metastases .  It still holds up well today although the C11 Pet scan he favors would probably be bettered by a later scan today such as the 68 Gallium PSMA.  Anyway, here is a link if  anyone is interested. 

 

4 hours ago, peniole said:

See explanation above Barry. You'll notice I talked about the zones, and specifically mentioned the symptoms of cancer arising in those zones not detected by a DRE. The urethral symptoms will give warning. Your link says the same thing but with less of medical explanation.

Also, those cases of GP vs urologist, again see above when I said with proper training. I've had the misfortune of dealing with GPs who were as thick as a plank. A urologist would have proper training, one would hope.

Just an FYI there is no such thing as a 100% accurate test. You take the best combination of sensitivity, specificity, positive and negative predictive values that you can get.

For example, a PSA test was thought to be good enough until it turned out to be not sensitive enough (missing cases), not specific enough (ejaculating, riding a bicycle, having a DRE or an infection are all things amongst a host of other non-cancer related things that can elevate your PSA), but good enough to follow a case post diagnosis/treatment after you have established a personalized baseline.

You see a screening test needs to be sensitive enough to catch most cases (notice I said most, not all), without over-diagnosing cases that don't need to be treated or non-cancer cases. The PSA failed on both accounts. Currently, the DRE is the only thing that fits that description until studies on the newer diagnostic modalities provide statistical evidence.

This is my bread and butter specialty. I'm an MD/PhD in oncological sciences researching and teaching this stuff for a couple of decades. Feel free to ask questions.

Thank you for your reply. I was aware of the comparatively recent research on helping to establish men more likely to have PCa and of course the need for a better test to replace initial PSA, the drawbacks of which you refer to. I am surprised that more progress has not been made in this area (although likely more challenging). By comparison, new and refined ways of treating have made great advances. So, I am somewhat surprised that so much credence is now being placed on the simple DRE, something I had in 2007 both by my GP and at urology but it raised no suspicion.  Thank goodness I also had a PSA test of 17.6 that rang bells and with a T3A staging was glad my GP added PSA test when checked for something else, although I had no symptoms of PCa.

With your long involvement in the area, you may remember 'The Great PSA Debate' that took place on 10th November 2009 with the likes of Sir Roger Kirby and Dr Chris Parker of the Royal Marsden, (the latter one of my consultants),.  on opposing sides with others for a motion at a great gathering of assembled, clinicians, and interested bodies and lay people.  The main motion was that every man at risk of PCa  (meaning men over 50, 40 with additional risk), should be encouraged to monitor his PSA on an annual basis.  The motion was passed by a large majority but never accepted into practise. 

Actually, having been diagnosed, my interest like most others on the Prostate Cancer UK  and an American forum I am member of, is more concerned with post initial diagnosis and treatments.  To this end, I did very extensive  research meeting some highly regarded Consultants in the UK and Germany.  This also involved reading medical papers, even from Japan, watching lectures and looking for trials in UK and Abroad.  I will not go too deeply into this as it may be found to be boring. 

Suffice to say, knowing how badly men suffer from PCa, I wanted to make men aware of the disease and a chance of early treatment if they accept the risks.

[PCM]

3 hours ago, Barry14UK said:

...Suffice to say, knowing how badly men suffer from PCa, I wanted to make men aware of the disease and a chance of early treatment if they accept the risks.

Well done.

[Herbie]

For what it's worth (and I appreciate it may not be worth much having read the comments in this thread) I've just got the email with my PSA results.

Previous tests have been 0.75, 0.75, 0.75, 0.52, and today's 0.55ng/ml.

[PCM]

5 minutes ago, Herbie said:

For what it's worth (and I appreciate it may not be worth much having read the comments in this thread) I've just got the email with my PSA results.

Previous tests have been 0.75, 0.75, 0.75, 0.52, and today's 0.55ng/ml.

It's worth a lot!

Healthy wishes to you.

[Malc]

Good luck everybody ...........  especially the ladies amongst us who must be bored rigid with all this prostate stuff reaching into relams of incredulity and non-understanding .......on my part anyway ( I'm pleased to say )

Jeez, fancy being a medical student having to come to grips with all this kafuffle ........  good luck to 'em, and us eh ! oh, and especially the ladies amongst us here 

Malc

[dutchie01]

21 minutes ago, Malc said:

Good luck everybody ...........  especially the ladies amongst us who must be bored rigid with all this prostate stuff reaching into relams of incredulity and non-understanding .......on my part anyway ( I'm pleased to say )

Jeez, fancy being a medical student having to come to grips with all this kafuffle ........  good luck to 'em, and us eh ! oh, and especially the ladies amongst us here 

Malc

Not sure Malc if there are a lot of them around on the LOC, really interested in knowing this, Anyone? And if there are how many of them will dive into a high quality read about prostate issues? Statistics statistics.

Anyway an incredibly interesting thread and i have learned more about my enlarged prostate than in talks with my GP. 

Again it shows the versatility and deep level of knowledge of the LOC and its members. 

[royoftherovers]

7 minutes ago, dutchie01 said:

Not sure Malc if there are a lot of them around on the LOC, really interested in knowing this, Anyone? And if there are how many of them will dive into a high quality read about prostate issues? Statistics statistics.

Anyway an incredibly interesting thread and i have learned more about my enlarged prostate than in talks with my GP. 

Again it shows the versatility and deep level of knowledge of the LOC and its members. 

I agree with you Bernard. The contributions from Barry 14UK and Peniole have been particularly interesting and informative. And without the bravery of Piers, non of this would have evolved.

[Rabbers]

15 minutes ago, dutchie01 said:

Not sure Malc if there are a lot of them around on the LOC, really interested in knowing this …

Some years ago I posted exactly this question on the IS Forum, innocently and, I think, politely.  There were no meaningful replies, and one or two barely stopped short of accusing me of misogyny (or whatever the fashionable term was at the time).

[peniole]

7 hours ago, Barry14UK said:

The main motion was that every man at risk of PCa  (meaning men over 50, 40 with additional risk), should be encouraged to monitor his PSA on an annual basis. 

Therein lies the devil, it's in the details. "with additional risk". It was an accepted mitigator to reduce the number of false positives, although not enough of time has gone by to show if this was statistically correct. Remember PSA was introduced in the 90's (See below the jump in diagnosis when it was introduced, I was still a med student back then), and it took the better part of 3 decades of data to come to the current conclusion. It'll take just as long to see if adding a risk factor other than just age will improve the reliability of PSA and reduce the unnecessary morbidity of biopsies and treatment when neither would have been needed. Something you said above is especially pertinent. Most men die with prostate cancer than from it.

Don't get me wrong, there's been plenty of advances in diagnostic techniques, it just takes decades of data, especially when we are taking about mortality rates ( so loooong follow up periods) for them to be validated. So expect another decade or more before we answer either question.

[cdmaskell]

On 8/24/2022 at 8:08 AM, peniole said:

Well done on getting a colonoscopy! Definitely worth it.

The PSA test on the other hand is no longer recommended as a screening test. Hasn't been for 2 years now. I should know, I teach this to med students. See: https://view-health-screening-recommendations.service.gov.uk/prostate-cancer/

A digit rectal exam on the other hand, no pun intended, is valuable.

What a minefield!  That pesky prostate gland. In 2018 I had backache, kept asking for a PSA test. It was 8/12.  After a colonoscopy PC was found in the prostate, it hadn’t escaped.  I was lucky to be put on trial at the Marsden Fulham.  I received the Cyberknife treatment over 5 days.  5/40 minute sessions.  August 2022 PSA 0.17. Let’s bring on the blood tests etc, just like breast and bowel. We shouldn’t have to wait for symptoms.  My backache was purely muscular.  I had NO other symptoms.  Peniole keep up the good work.  Piers, all the best.

[peniole]

1 hour ago, cdmaskell said:

What a minefield!  That pesky prostate gland. In 2018 I had backache, kept asking for a PSA test. It was 8/12.  After a colonoscopy PC was found in the prostate, it hadn’t escaped.  I was lucky to be put on trial at the Marsden Fulham.  I received the Cyberknife treatment over 5 days.  5/40 minute sessions.  August 2022 PSA 0.17. Let’s bring on the blood tests etc, just like breast and bowel. We shouldn’t have to wait for symptoms.  My backache was purely muscular.  I had NO other symptoms.  Peniole keep up the good work.  Piers, all the best.

Glad you dodged that one Colin. No you shouldn't have to wait for symptoms. Sadly a lot of cancers still don't have adequate screening tests (e.g. pancreas, uterus, ovary...etc.).

The two bright spots are cervical and breast cancer screening, and now we have a vaccine for cervical. Although with deferred screening because of the pandemic, we're expecting an uptick in late stage cancers. Not good.

Lots of work still to be done. My thesis supervisor used to joke about it, and don't judge him too harshly he's a great and brilliant guy, he called it job security.

[cdmaskell]

I didn’t have private health insurance. Would you recommend, under the right circumstances that men who have,  push for the “Cyberknife”?   It had minimum side effects, and the bonus 3 gold seeds markers in the prostate!  You have a been great help to the people in the Lexus Club. Thank you.

[rayaans]

The PSA is a crap screening test and affected by multiple factors. Go for a run - elevated. Constipated - elevated. Urine infection? elevated. Prostatits - Elevated. The list goes on and on. 

Sometimes the PSA is not raised and a cancer is there.

DRE - you can probably tell the size of the prostate and if its tender. Boggy is easy to feel for but youve got no chance reliably saying that a cancer can be picked up by a DRE unless its massively obvious. A biopsy is the gold standard. 

Most with prostate cancer will live with the condition and die from something else by the way. The 10 year survival rate is well above 90%

[peniole]

47 minutes ago, cdmaskell said:

I didn’t have private health insurance. Would you recommend, under the right circumstances that men who have,  push for the “Cyberknife”?   It had minimum side effects, and the bonus 3 gold seeds markers in the prostate!  You have a been great help to the people in the Lexus Club. Thank you.

Not as simple as recommending one procedure over another, center expertise plays a big role in the outcome. Cyberknife is plainly radiation therapy, that's been around for eons, but the cyberknife takes out surgeon/user skill and replaces it with a robot that does the monitoring and moves the radiation in response to what you, the patient, are doing. In the end it's still a rather blunt instrument. Any cell exposed to radiation dies, which is why the robotic precision is so important. How many times did they tell you to hold still?

I prefer molecularly targeted therapies. That's is where we figure out why/how the cancer happened, and specifically shut down that pathway. Unfortunately, we haven't figured out each and every pathway in every cancer. Some prostate cancer patients for example may have a BRCA mutation. That's a gene that is responsible for fixing DNA breaks. Also known to be mutated in breast cancer. We have a therapy that specifically screws with this pathway, they're called PARP inhibitors (see: https://www.cancer.org/cancer/prostate-cancer/treating/targeted-therapy.html). What these guys do is further inhibit the cell's ability to fix DNA, but only cells that have BRCA mutations (i.e. in this case the prostate cancer cells) will end up with so much damaged DNA they end up dying. Minimal side effects because your normal/non-cancer cells aren't severely hit by it .The problem, not all prostate cancer patients have BRCA mutations. So the search continues for these chess like opportunities and there's been plenty of breakthroughs over the years.

https://www.cancer.gov/about-cancer/treatment/types/targeted-therapies

https://www.pennmedicine.org/cancer/navigating-cancer-care/treatment-types/immunotherapy/targeted-therapy

https://www.macmillan.org.uk/cancer-information-and-support/treatments-and-drugs/targeted-therapies

[peniole]

28 minutes ago, rayaans said:

DRE - you can probably tell the size of the prostate and if its tender. Boggy is easy to feel for but youve got no chance reliably saying that a cancer can be picked up by a DRE unless its massively obvious. A biopsy is the gold standard.

I agree with everything else in your post but this quote. Yes, a biopsy is the gold standard for diagnosing every single cancer, no exceptions. But how do you decide who to biopsy? You can't biopsy the whole population. A biopsy is not a screening test. It is too invasive.

[rayaans]

4 hours ago, peniole said:

I agree with everything else in your post but this quote. Yes, a biopsy is the gold standard for diagnosing every single cancer, no exceptions. But how do you decide who to biopsy? You can't biopsy the whole population. A biopsy is not a screening test. It is too invasive.

True, but you can't do a PSA on everybody either as it'll show up too many people who end up getting a biopsy or MRI on their prostate.

I mean certain red flags like ejaculating blood would prompt a 2 week wait referral and a reasonably high PSA but other than that its very hard