PSA, The Human “Check Engine” Light

BY MARK SCHOLZ, MD


Why all the controversy about PSA? How can people fault a simple blood test that uncovers cancer at an early stage? The problem is that the PSA test doesn't specify what type of cancer the patient has. In addition to the presence of cancer, there are two other common causes of PSA elevation—prostate gland enlargement that comes with age, called BPH, and chronic prostate inflammation, called prostatitis.

PSA by itself doesn’t diagnose prostate cancer.  It is a nonspecific indicator, like the “check engine” light on the dashboard of your car.*  Does this eliminate the value of PSA?  Of course not.  An elevated PSA reading is a useful indicator of the need for further research into the cause.

The biggest fear--and the primary argument used by PSA naysayers--is that so many urologists recommend immediate random biopsy with any PSA elevation whatsoever.  A million men are biopsied annually in the US, resulting in the over-diagnosis of innocuous prostate cancers in about 100,000 men each year.  Most of these men end up undergoing unnecessary radical surgery or radiation.

So how do we eliminate the bathwater (random biopsies) without throwing out the baby (PSA)?  The first step is avoiding the trap of rushing headlong into something before learning the whole story. Since we know PSA is nonspecific, most elevations will be from prostate enlargement, not cancer.  PSA needs to be interpreted in relation to prostate size.

One might think that only ultrasound or MRI can reliably measure prostate size.  And while imaging is indeed the most accurate method, practiced doctors can roughly estimate prostate size with a simple digital prostate exam.  Also, there is a PSA blood test variant called “free” PSA that is suppressed in men with BPH.  Free PSA is reported out as a percentage of total PSA.  When free PSA percentage drops below 10%, BPH as a cause for PSA elevation is less likely.

Sequential PSA testing is the best way to diagnose inflammatory prostatitis, the other common reason for benign PSA elevation. Inflammation can increase PSA, which often oscillates up and down as the inflammation in the gland waxes and wanes.  This bouncing PSA pattern is in sharp contrast to an elevation of PSA caused by cancer.  A rise in PSA from cancer is usually unidirectional—up, up and up.

Historically, despite the drawbacks from biopsy of over-diagnosis, infections and discomfort, it has been the gold standard for diagnosing prostate cancer. Only very recently have new advances in multiparametric MRI imaging enabled men with PSA elevation to consider this imaging alternative--rather than random biopsy--as a first step. Our recommendation to use a multiparametric MRI (at a center of excellence) followed by a targeted biopsy if a suspicious lesion is detected, has been discussed in more detail in previous blogs. 

*I wish I could take credit for the check engine light idea that so nicely conveys the useful but nonspecific character of PSA.  This little pearl of knowledge was passed on to me by a patient. 

In Praise of Feisty Patients

RALPH BLUM

I have learned through personal experience that there is an art to being a patient. You must choose wisely when to submit and when to assert yourself, especially if you have just been diagnosed with prostate cancer.

Because prostate cancer is so common, and in most cases so slow growing, to submit  to any form of radical treatment without doing your due diligence, could be a serious mistake and hugely detrimental to your quality of life. Yet most doctors you consult will advocate some form of radical treatment. It’s what they know, what they do. And it goes against the grain for both doctors and patients alike to put off treating prostate cancer.

However,  let’s take a moment and put things in perspective. Fifty percent of older men have the disease, live with it, and die from something else—sometimes without ever knowing they had a life threatening condition. Furthermore, the life expectancy of men with recurrent prostate cancer often stretches out well past a decade. And yet the radical prostatectomy-- one of the most complex and challenging surgeries because the prostate is located in absolutely the wrong place for a simple surgical solution—is still the most widely recommended treatment option, the most often unnecessary, and the one most likely to leave you incontinent and/or impotent.

My own experience with urologists has not always been a happy one. Twenty-five years ago, a Honolulu urologist who wanted nothing but patient compliance, told me that if I did not agree to immediate surgery I would be dead in two years. His recommendation and prognosis were not only wrong, but in my opinion violated the ancient medical precept incorporated in the Hippocratic Oath: “First do no harm.” Fortunately I was not the kind of patient to be easily intimidated.

My decision to engage in watchful waiting, monitor the cancer and take the time to educate myself, has given me almost three decades of quality time with my wife that almost certainly would have been lost or diminished if I had committed to immediate surgery. The feisty, “difficult,” assertive patient, the one who challenges the doctor, is often the one who has the best outcome.

If I had it all to do over again, I would seek to change nothing.

 

The Importance of Good Communication

RALPH BLUM

You know how frightening it was for you to hear that you have prostate cancer, but in your state of shock you may not realize it is just as devastating for your partner. Although you are the one with the cancer, and the one who has to struggle to cope with selecting the best treatment, your partner is likely experiencing the same emotional distress. The diagnosis inevitably brings up a whole lot of fear for both of you--fear of what’s going to happen, the unthinkable fear (but one you can’t avoid thinking about) that you might die, fear about how sick you will get, fear about what effect your treatment will have on you, fear of how this will change your life together.

The most important thing you can do to deal with these fears and emotions, both yours and your partner’s, is to maintain good communication. The problem I have seen is that some men react to a diagnosis of prostate cancer by pretending that everything’s going to be fine. They don’t want to talk about it. They think asking for help is unmanly, and they want to protect their partner. And most of all they don’t want to talk about their feelings and fears.  But putting on a brave front and shutting out your partner is not a good strategy.

I struggled through this experience with my partner, Jeanne.  After almost a quarter of a century of doing active surveillance my PSA spiked to a troubling level without any obvious medical evidence as to why. This change in my condition really upset Jeanne. I sought to reduce her fears (and mine) by explaining to her - my belief that my cancer was no more aggressive, but rather because I of my advancing in age my immune system was no longer the faithful bulwark it had been when I was younger. I told her that as a result I was going to get  treatment--which treatment, and why.

Basically, I settled on Intensity-Modulated Radiation Therapy (IMRT). So I took some time explaining my reasons.  My decision was the result of two "benign" characterisrtics of IMRT. First, the beams were very unlikely to damage to the healthy tissue they traversed, targeting only cancer cells. Second, the process of apoptosis or cell death, would continue unassisted, for up to 18 months following termination of the IMRT procedure.

It is vital that you communicate with your partner openly and honestly.  You need to talk about the possible problems that may occur, about how this disease will affect both of you, how you feel about what is happening, or not happening, in the bedroom. You need to share with your partner all the information you have because it can help alleviate fears and concerns. And whenever possible enlist your partner’s help in gathering information about prostate cancer treatments and analyzing which treatments may have the best results.

Make sure your partner understands up front that although prostate cancer is a major problem it is highly treatable and, in most cases, not life-threatening. Above all, resist hiding your feelings because you don’t want to add to your partner’s already heavy burden. It’s one thing to be positive when you can, but you are not doing any favors to the person you love by pretending that you are not afraid or not depressed. You are in this together. Blessed be!

Radiation for PSA-Relapsed Prostate Cancer, an Alternative to Lifelong Lupron

BY MARK SCHOLZ, MD

About 60,000 men a year relapse after surgery or radiation with a rising PSA. In the old days, a rising PSA after surgery was treated with radiation to the prostate fossa, the area of the body where the prostate was previously located.  One-fourth of the time these treatments cause durable lowering of PSA levels, essentially a cure. The other three-fourths of the time the PSA keeps rising and the men are relegated to lifelong hormone therapy with Lupron shots.  This article is about what to do for the three-fourths whose PSA keeps rising despite undergoing radiation to the prostate fossa.

While hormone therapy is the standard approach because it effectively suppresses PSA for over ten years, the quality of life on long term Lupron is often poor, because Lupron causes hot flashes, tiredness, joint aches, muscle atrophy and loss of sex drive. 

In the old days crude attempts to improve cure rates were made by extending the radiation field outside the prostate to cover the pelvic lymph nodes. (The lymph nodes are the first jumping off place for prostate cancer when it metastasizes outside the gland.) As might be expected the closely surrounding intestines often are caught in the radiation crossfire, creating nasty digestive disturbances such as chronic diarrhea and intestinal bleeding. However, due to an amazing breakthrough in radiation technology, that occurred in the mid-1990s— intensity modulated radiation (IMRT)—now the radiation beam can be sculpted to target the nodes and miss the intestines.

Excitement about the potential for this new technology ramped up even further with the advent of new cancer scans such as Combidex and C11 PET scans that can accurately detect which lymph nodes are diseased.

Let me recount the story of a PSA-relapsed gentleman who has now passed his fifth anniversary off Lupron, with this revolutionary approach. Initially, in 1992, he underwent a prostatectomy, but by April of 2003 his PSA had risen to 0.07. He was treated with standard radiation to the prostate fossa. His PSA briefly dropped, but by February 2007 it was back up to 1.83 and in May 2008 his PSA was 7.3.  A Combidex scan showed cancerous lymph nodes extending from the pelvis up through the abdomen all the way to the diaphragm. He started Lupron and Casodex and underwent another Combidex scan in June 2009 that showed substantial improvement but incomplete resolution of the cancerous nodes. He started IMRT directed at all the cancerous nodes in late July 2009. The Lupron was stopped in June 2009. At his last visit to my office in November 2014, testosterone was normal at 433 and PSA was 0.040.

Sometimes a “breakthrough” in medical care simply results from a new application of existing technology.  This case illustrates how the results of targeted treatment with IMRT can be further enhanced with optimal scanning technology to achieve durable remission and freedom from lifelong dependency on hormonal therapy.

Did I hear you say “direction?” That you’d lost your direction?

RALPH BLUM

Apparently loss of hearing isn’t the only loss we’re subject to in these latter years. Oh well, “Direction, erection—as long as you’ve still got your health, right?

The first breakthrough in treating erectile dysfunction (ED) came at the 1983 American Urological Association meeting in Las Vegas when Dr. Giles Brindley injected his penis with the drug phentolamine. Following the injection, Dr. Brindley appeared on stage and dropped his pants to display one of the first recorded, drug-induced erections to a startled audience of urologists and their wives.

It wasn’t until 1998, when the FDA gave Pfizer the go-ahead for their little blue pill, that erectile dysfunction (ED) came out of the closet, and, thanks to Viagra, men no longer had to self-inject their penis or use a vacuum pump in order to get and keep an erection, aka “hard-on.”

In case you wondered, “hard-on” is a synonym for “boner” or "blunder," 1912, baseball slang, probably from bonehead. The meaning "erect penis" is 1950s, from earlier bone-on (1940s), probably a variation (with connecting notion of "hardness") of hard-on (1893). Sure as shooting, many a hard on has resulted in blunders! Still, losing our “blunder-making ability—erectile dysfunction or ED—is of serious concern to a great many men.

Today, it is estimated that up to 30 million American men frequently suffer from ED. For those of us who are over seventy, the hydraulics of nature’s ultimate erector set are subject to ordinary fatigue and malfunction. Many of us are dealing with the after-effects of prostate cancer treatment. And there are dozens of other reasons, both medical and emotional, for the inability to get or maintain an erection.  So without a doubt there is a humongous market for what my young neighbor calls “boner pills,” and last year alone Pfizer spent $176 million on TV ads for Viagra.

Although it is almost impossible to turn on your TV without seeing a commercial about erectile dysfunction, until recently the content of those ads, while excellent fodder for comedians, has been fairly subtle—usually involving an attractive middle-aged couple making goo-goo eyes at each other, building up to the magic point “when the moment is right.” It may be hokey, and a trifle awkward to explain to your 10-year-old daughter what Viagra is all about, but the ads were not totally gross.  Then Pfizer changed their ad agency…

The latest Viagra commercial features a glamorous blonde in a slinky blue dress reclining on what appears to be a mattress. Looking directly into the camera, and in a sexy, sultry voice with a British accent, she addresses the viewer: “So guys, it’s just you and your honey. The setting is perfect. But then erectile dysfunction happens again.”  She then takes a stroll through a tropical setting and adds, “You know what, plenty of guys have this issue—not just getting an erection, but keeping it.”  (Incidentally, this is the first use of the word “erection” in a TV ad outside of the description of side effects.)

The new face of erectile dysfunction is an English soap actress called Linette Beaumont, and she is prompting a Twitter storm. One viewer tweeted: “Don’t need Viagra. Just need the hot blonde with the British accent.”  A less enthusiastic viewer tweeted: “Nothing is worse than sitting next to your grandma while a hot blonde British woman talks about erections. Thanks, Viagra.”  I haven’t yet seen any of the late night talk shows, but I imagine the hosts are having a field day.

No doubt about it, Viagra has helped countless men to maintain an active sex life.  But do we really need this kind of advertising to get a rise out of men (pun intended)?

Why Big Prostates Are Good

BY MARK SCHOLZ, MD

Whenever the prostate gets mentioned, excess enlargement is frequently mentioned, as if increased size is the root of all evils. So what follows may surprise you: Having a big prostate can be desirable. For example, studies show that as the prostate gets larger, prostate cancer grade tends to become lower. And the frequent urinary problems that are so often blamed on a big gland often result from other causes.

Sound strange?  The urinary tract is far too complex to simply blame everything on a big prostate gland.  For example, take the almost universal complaint of aging males who say that they go to the bathroom too often.  Or consider the companion complaint, urinary urgency, which results in getting up frequent urination at night. Clearly these common problems are not restricted only to men with big prostate glands. Men with normal sized and even small glands have the same problem.  Even women suffer these problems and they have no prostate at all.

In this short blog it’s impossible to address every possible reason for urinary frequency. However, a couple of rather obvious matters are often overlooked.  First, consider the common mantra that it’s healthy to drink eight glasses of water daily.  Come on people!  The body does not digest water.  All the water that enters the body must come out somewhere. Need I say more?

But completely separate from the fact that our culture slugs down huge amounts of water daily, older people also typically experience a strengthening urge to urinate as we get on in years.  Why is this?  Think about it.  Most urges and sensations grow weaker with age.  Eyesight dims, libido fails, hearing diminishes. What a mess we would be in if our urge to urinate faded away too. The progressively stronger urge to urinate is a built in protective measure to ensure continued healthy function of the urinary tract. If a man loses his urge to urinate he ends up with a chronically indwelling catheter to drain his nonfunctioning bladder.

This is not to say that the increasing urge to urinate is convenient.  And a variety of over-the-counter and pharmaceutical agents have been marketed to help temper the intensity of the urge. It’s just not accurate to place all the blame on prostate enlargement. Moreover, several studies show that larger glands tend to generate lower grade cancers. Studies also show that men with smaller prostate glands have more extra-capsular spread and higher cancer recurrence rates after surgery compared to men with big glands.

The cause for less aggressive disease in men with larger prostate glands is unknown. Some researchers have postulated that men with big prostate glands, since they run higher PSA levels, get subjected to biopsy more frequently, and thus are diagnosed with cancer at an earlier stage. However, studies of men who have been diagnosed by the detection of a palpable abnormality (a semi-advanced stage) rather than by PSA, show the same pattern of having a better grade when the prostate is enlarged.

Perhaps someday scientists will be able to explain these mysterious disease patterns.  And having a big gland is not always good; there are indeed some men with big glands who suffer urinary blockage symptoms. For now, however, men with big prostates can be thankful that their large gland has some sort of a protective influence over prostate cancer. 

Remember: In BPH, the “B” stands for “Benign”

BY RALPH BLUM

The prostate gland is the only organ in our body that keeps growing as we get older; all our other organs shrink and atrophy over time. A healthy prostate gland weighs around half an ounce (15 grams) in young men, and an ounce (30 grams) or more in men who are 50 or older. However, the prostate can weigh over 100 grams, in some cases causing problems with urination.

Although an enlarged prostate doesn’t inevitably lead to problems, one-third of all men older than 60 have benign prostatic hyperplasia (BPH) that causes urinary symptoms. The most common urinary symptoms are:
 
— Frequent urination.             
— A slow, weak stream of urine—there may be a lot of stopping and starting.
— A feeling of urgency when you feel like voiding.
— Painful, almost total blockage (this requires immediate medical treatment).

If you are having any of these urinary symptoms, in addition to a urine test to rule out a bladder infection, you will need an ultrasound scan to measure the size of your prostate gland, and to determine the nature and seriousness of the problem.

In most cases BPH can be treated with a category of medications, known as alpha blockers, that relax the prostate and make urinating easier. The best known of these is Flomax (generic name: tamsulosin). Another standard treatment is Proscar (generic name: finasteride) that works to shrink the size of the gland and, therefore, reverse the problem of slow urination from prostate enlargement.

However, if your symptoms are severe and/or multiple, you may require treatments using microwave, laser or electrical energy. Or if total blockage occurs, your urologist will perform transurethral resection of the prostate (TURP), a surgical procedure that removes the prostate tissue that is blocking the flow of urine.  This procedure is sometimes referred to as a “rotor-rooter job.”

BPH is the most common reason for urinary problems in older men. But equally important is the fact that an enlarged prostate causes a rise in PSA. The reason for this elevation is because the level of PSA measured in the blood is not only proportionate to the number of cancer cells in the prostate gland, but also to the size of the gland. If, therefore, the PSA level is appropriate for the size of the prostate, and if ultrasound imaging fails to reveal any sign of cancer, chances are the PSA elevation originates from BPH. In which case, active surveillance with regular PSA testing and occasional prostate imaging is, without a doubt, preferable to biopsy.

 

But the overwhelming concern of most doctors is that they might miss cancer in their patients. That concern, plus our own fear of the disease, far too often makes us jump to an immediate, unnecessary biopsy. And here’s a fact to tape to your shaving mirror:

 

--More than half the prostate biopsies performed annually

in the U.S. are done for evaluation of an elevated PSA

caused by Benign Prostatic Hyperplasia.

 

Isn’t it time we got smarter and started acting out of knowledge, instead of out of panic? And to remember what the “Benign” in BPH stands for?

 

VIDEO: Learn more about High PSA, Multiparametric MRI and random biopsies  http://youtu.be/6QgcfVBzFNs

 

 

Aspirin Lowers Prostate Cancer Mortality Rates

BY MARK SCHOLZ, MD

If a man wants to tilt his odds in favor of a longer life, he wears a seat belt, eats a good diet, gets an annual medical checkup, exercises and gets married. Yes you heard me right, he gets married.  The November 2013 issue of the Journal of Clinical Oncology reports that the risk of dying from prostate cancer was 25% lower in married compared to single men.

Yet one intervention that also has merit and that often gets overlooked is the lowly aspirin pill. Aspirin is well-established as a beneficial agent for reducing cardiac risk.  It cuts the risk of heart attacks by about 30%, a rate of reduction similar to common statin medications like Lipitor and Crestor.  A risk reduction of this degree is notable considering that heart disease is the most common cause of death in men, especially in men with prostate cancer since most of them are over age 50.

I bring the issue of aspirin to light in this blog because I want to emphasize that there are further benefits of aspirin beyond the cardiac benefits. Specifically I want to cite another article published in the Journal of Clinical Oncology in October 2012, which reports that aspirin reduces prostate cancer mortality rates. Let me paraphrase the main take home message from the article: The difference in prostate cancer specific mortality between the men with prostate cancer on aspirin compared to the men with prostate not taking aspirin was most prominent in patients with high-risk disease.  The ten year prostate cancer specific mortality was only 4% in the men taking aspirin compared to 19% in the men who were not.  For men in the intermediate-risk group mortality was reduced from 6% down to 3% by taking aspirin.

So, in addition to the known cardiac benefits, aspirin also has a potent anticancer benefit.  Incidentally, other studies have shown that aspirin has an anticancer benefit for other types of cancer besides prostate cancer.

Aspirin is not totally risk free.  For example, one out of 200 can get a bleeding stomach ulcer.  People taking aspirin who develop black stools or heart burn should stop and get further medical evaluation. Despite these risks, aspirin can clearly be beneficial in a large number of people.  Just because it is cheap and readily accessible don’t be fooled into discounting its undeniable value.

Finding a Skilled Specialist

BY RALPH BLUM

Your number one priority when you have an elevated PSA and prostate cancer is suspected, is to take the time to find the very best urologist in your area. What you need now is an experienced urologist who specializes in treating prostate cancer, a urologist who is up on all the latest medical knowledge and surgical techniques, and who will thoroughly discuss all viable treatment options with you in an even-handed manner.

Your options might include nerve-sparing prostatectomy, radiation (IMRT and seed implants), cryosurgery, proton beam therapy, hormone therapy, and Active Surveillance. All prostate cancer treatments have their risks and benefits, and sometimes your best decision is no immediate treatment. I strongly suggest that you take the time to do some Internet research so that when you see the urologist you have some knowledge of the various treatments and their side effects, and know what questions to ask.

Before making any treatment decision you should also talk with a medical oncologist.  Urologists are surgeons, so if the cancer is contained within the gland, it’s not surprising that their treatment of choice would be surgery. But if you have done your homework, you will know that a prostatectomy is a complex procedure that can leave you with considerable collateral damage. Similarly, radiation therapists will likely recommend one of the targeted radiation options. However, a medical oncologist has no vested interest in either approach and is familiar with all the treatment options, so he is uniquely qualified to help you decide which treatment to select.

Your primary care doctor usually knows the names of the best local urologists and oncologists in your area. But you may want to go beyond your local area to find a specialist, in which case you can network--ask your friends if they know of any good doctors for treating prostate cancer. Search prostate cancer Web sites. Ask any doctors you have ever consulted who they would see if they had the disease. And most states have prostate cancer support groups that provide excellent advice.

Before making a final treatment decision, it is critically important to get a second opinion, preferably from a highly trained urologist, medical oncologist or radiation oncologist at one of the major cancer centers. Second opinion consultations are standard procedure; your doctor makes such referrals all the time, and a second opinion is reimbursed by most insurance programs. One other thing, be sure to take a complete transcript of your medical records with you.

Above all, don’t rush to make any pivotal decision that could influence the rest of your life while you are still in shock from the diagnosis. You have plenty of time to make sure you are selecting an experienced doctor, and one with whom you feel comfortable, and who gives you confidence.

Raising Awareness about MRI Imaging of the Prostate

BY MARK SCHOLZ, MD

Prostate cancer screening presents a unique challenge.  Prostate cancer is a very common, but only a minority of cases are deadly.  This creates a serious problem.  It’s good to detect high-grade disease because early treatment reduces mortality.  But PSA screening detects a lot of men with low-grade disease and these men are harmed. Why? Well-intentioned but over-enthusiastic doctors recommend treatment even though it’s truly medically unnecessary. 

Why We Over Diagnose
So what can be done?  Physician propensity for overtreatment will only change slowly.  The shortest pathway out of this dilemma is to stop diagnosing so much low-grade disease.  The crux of the problem is the random needle biopsy, a “blind” procedure that is widely considered to be the necessary first step for evaluating elevated PSA.  A million men undergo biopsy annually; 250,000 men are diagnosed; around a 100,000 have low-grade disease the can be safely monitored with “active surveillance.”

The Next Evolutionary Step
Three-Tesla multiparametric MRI (MP-MRI) scans developed by Siemens, Philips and GE can reliably detect high-grade disease without over diagnosing low-grade disease; these scanners accurately differentiate high-grade from low-grade tumors.  The availability of these new scanners makes random biopsy as currently utilized by most urologists archaic. Random biopsy involves inserting 12 needles into the rectum.  Beyond its propensity for over-diagnosis, 3% of men are hospitalized with serious infections.  Also, it is relatively inaccurate, failing to detect high grade disease over 15% of the time.

New Technology Growing Pains
Most internists and urologists are still unaware of these important technological advances.  Even those who are aware are still learning how to translate these new imaging reports into practical recommendations for their patients. Also, there is the challenge of maintaining quality control in this rapidly expanding world.  Despite these barriers the advantages of using imaging as a first step can’t be ignored.  PCRI has posted a list of centers that perform this type of imaging.  While we have some familiarity with these centers, for liability reasons we are unable to offer any official certification of their quality and accuracy.  On the other hand, new as this technology is, we feel it would be a disservice not to spread the word about its availability.

CHECK OUT THIS VIDEO: SO YOUR PSA IS HIGH, NOW WHAT? http://youtu.be/6QgcfVBzFNs

First Stop on the Overtreatment Express: The Unnecessary Biopsy

RALPH BLUM

The first four words of the subtitle of our book, Invasion of the Prostate Snatchers are, “No More Unnecessary Biopsies.” At the appropriate time, a biopsy is an essential diagnostic tool. Unfortunately, however, far too many urologists still schedule an immediate biopsy if there is even a slight rise in PSA. And that has led to a multi-billion dollar industry bent on administering treatment to every kind of prostate cancer, whether it is life-threatening or not.

So what do you need to know before agreeing to submit to a biopsy? There are several possible reasons for an elevated PSA besides cancer:

1. A prostate infection, in which case a simple course of antibiotics may be all it takes to lower PSA into the normal range. Years ago my PSA went zooming up from an infection.

2. PSA rises after sexual activity, so abstinence is necessary a day or two prior to testing.

3. Recent bicycle riding activity can cause an elevated PSA.

4. An enlarged prostate—aka Benign Prostatic Hyperplasia, or BPH—usually results in an elevated PSA. More than half the biopsies in the U.S. are performed for evaluation of an elevated PSA coming from BPH.

5. A random laboratory error is always a possibility, and occurs more often than we realize.

So rather than triggering the scheduling of an immediate biopsy, an “abnormal” PSA should set a risk-assessment process in motion. The first step is to eliminate any of the above possible causes—checking for an infection, repeating the PSA to see if a lab error caused the elevation, performing an ultrasound scan to determine the size of the prostate to see how much BPH is present, and to determine whether the ratio between PSA and prostate size is in the expected range.

 

If these measures all fail to explain the elevated PSA, further testing—with an OPKO-4K blood test that is specific for high-grade cancer—should be considered before resorting to a biopsy. Other useful procedures prior to undertaking a biopsy are color Doppler ultrasound and/or multiparametric  MRI. Imaging studies provide an accurate measure of the prostate size so that the PSA “density” (PSA elevation in the context of prostate size) can be calculated.  If  the OPKO-4k,  PSA density and imaging are favorable, then surveillance with periodic PSA and  imaging, may be preferable to an immediate biopsy.

 

You have probably realized by now that I am not a fan of biopsies.They can be painful, can cause erectile dysfunction, and fail to spot cancer as much as 20% of the time, especially in men with large prostates. But the main reason I am against unnecessary biopsies is because of the unnecessary radical prostatectomies that usually follow—estimated at above 80,000 annually in the U.S. alone. Having a biopsy is like opening Pandora’s box.

 

According to Thomas Stamey, M.D., who developed the PSA blood test, prostate cancer is a disease that almost all men get if they live long enough. So the older the man, the more likely a biopsy will reveal cancer. But that doesn’t mean every man should have his prostate removed. However, only too often, that is what happens. The treatment of choice of most urologists is surgery (they are, after all, surgeons), and most men yield to the emotional appeal of “cutting it out.” This unfortunate situation is what led to Stamey’s famous quote: “When the final chapter of this disease is written, it will prove that never in the history of oncology will so many men have been so over treated for one disease.”

 

An unwarranted biopsy is the first stop on the Overtreatment Express.

Avodart & Proscar

BY MARK SCHOLZ, MD

Frequently I am asked about Proscar and Avodart, two medications that are FDA approved to reduce urinary side effects from prostate enlargement (BPH).  It turns out that these medications have a much wider spectrum of application than simply treating BPH. They function by blocking a type of testosterone called dihydrotestosterone (DHT) that occurs primarily inside the prostate. A short blog can’t summarize this vast field.  However, I think even a brief review might be helpful.  Here is a list of their potential applications:

• Lower the risk of being diagnosed with prostate cancer
• Improve the detection rate of high-grade prostate cancer
• Cause Gleason 6 cancer to regress or be suppressed
• Synergize with other hormone therapy medications (such as Casodex)
• Help maintain men on active surveillance to avoid surgery or radiation
• Prolong the “holiday period” in men on intermittent hormone therapy
• Reduce male pattern baldness
• Delay orgasm in men with premature ejaculation

The occasional side effects that can occur, such as reduced libido, impotence and breast enlargement, are manageable or preventable as long as the medication is stopped in a timely fashion when side effects occur.

In a randomized study comparing Proscar with placebo, 10,000 men underwent a prostate biopsy. The Proscar-treated men were diagnosed with cancer 25% less frequently compared to placebo. However, enthusiasm for the routine use of Proscar to prevent cancer was dampened when the same study reported a 1% increased incidence of diagnosing high-grade prostate cancer. Even though many experts hypothesized that Proscar was increasing the detection rate, not causing high-grade disease, Peter Scardino, a prominent urologist from Memorial Sloan Kettering published an opinion that Proscar could be causing high-risk cancer, raising all kinds of consternation and inciting the FDA to place a warning. Fortunately, subsequent follow up published in the August 15, 2013 issue of the New England Journal of Medicine showed that after 18 years of observation there was no increased prostate cancer mortality from Proscar.

Much of what is known about Proscar can also be said about Avodart. Both agents block 5- alpha reductase (5-AR), an enzyme that converts testosterone into DHT.  A possible advantage of Avodart is that it blocks two of the three forms of 5-AR whereas Proscar only blocks one.  No clinical trials, however, have been performed to compare clinical efficacy of the two agents.  In our in-house trials we have found that DHT blood levels are lower with Avodart than Proscar.

Since both Proscar and Avodart lower PSA by about 50%, the question arises, “Are they masking the capacity of PSA to signal cancer progression?”  Briefly, the answer is no. These medications do not stop a PSA rise in men with progressive cancer. However, after starting Proscar or Avodart the PSA baseline does reset 50% lower. On average, a man with a PSA of 6.0 before starting Proscar will drop to 3.0 within a few months. Subsequently, if the PSA rises consistently above 3.0, cancer progression should be entertained as a possible cause.

The rationale for concluding these agents are beneficial when added to other hormonal agents is based on the known fact that no pharmaceutical drug by itself can totally eradicate or block testosterone. So logically, the addition of a nontoxic 5-AR inhibitor to further lower DHT is likely to be helpful. Studies show that these agents suppress PSA in men with relapsed disease, delaying the rise in PSA, on average, for a couple of years.  It has also been shown that these agents can double the duration of the “holiday period” in men on intermittent hormone blockade.

Proscar and Avodart—mild agents with mostly reversible side effects—almost never interact with other medications.  They can be taken anytime of the day, with or without food. Proscar is available as a generic called finasteride and is very affordable. There is certainly an important role for these well-tolerated medications though in this era of new, high-powered hormonal agents such as Zytiga and Xtandi, Proscar and Avodart often get forgotten.  

Read another Prostate Snatchers blog written on Avodart & Proscar here:  http://prostatesnatchers.blogspot.com/2011/05/avodart-proscar-for-men-on-active.html
 

How to Cope with a Prostate Cancer Diagnosis

BY RALPH BLUM

There is no easy way to receive the news that you have cancer of any kind, but—and I cannot say this too often‑—it is important to realize that prostate cancer is typically not a death sentence. The majority of men diagnosed with prostate cancer have Low-Risk disease and will live a normal life span. And even more aggressive High-Risk type is now being successfully treated with a combination of therapies.

Having said that, a diagnosis of prostate cancer is daunting, and once you join the ranks of the newly diagnosed, you enter into what Mark calls “a medical minefield.”  While you are still reeling from shock you are required to make treatment decisions that can permanently affect your quality of life, and there are no easy answers. There are, however, a few basic things to bear in mind while you navigate the prostate cancer minefield.

1)    Don’t waste energy asking yourself, “How did this happen? Did I bring this on myself?” Because regardless of your lifestyle—eating habits, exercise regime, or anything else that might contribute to getting this disease—you did not cause it. Prostate cancer is incredibly common. Like diminished sight and hearing, it comes with advancing age.  In the words of one prostate oncologist, “If you are over seventy, and you don’t have prostate cancer, chances are you’re a woman.”

2)    Stay as calm as possible. The very process of gathering the information necessary to make an informed decision can be scary. But do not be panicked by all the numerical tables, statistics and graphs. Statistics measure populations. You are not a statistic. You’re a person. And statistics and pathology reports do not take into account all the variables and intangibles that make you an individual.

3)    Be proactive. The days of the passive patient with a “Whatever-you-say-Doc” attitude are over. The single most influential decision maker when it comes to obtaining the best care and treatment is you. Do your own research, and become actively involved with your doctor in the decision-making process. Ask your doctor about all your treatment options, and make sure you understand their short-term and long-term side effects.

4)    Recognize and resist your natural desire to rush into radical treatment. Be aware that a combination of the urologist’s preference for surgery and most men’s “just get it out” attitude, leads to tens of thousands of unnecessary radical prostatectomies every year. These men would have lived just as long without surgery, without the risk of losing both potency and normal urinary function and greatly compromising their quality of life.

5)    Even if you are satisfied with your urologist, it is critically important to get a second opinion, preferably from an independent board-certified medical oncologist—a cancer specialist—and if possible, an oncologist with a specialty in prostate cancer. Obtaining a second opinion doesn’t imply that you don’t trust your doctor. On a decision this important, you owe yourself the benefit of more than one person’s thinking.  Be prepared for conflicting opinions, and remember to trust your instincts about which doctor is right for you. Finding the right doctor may require traveling to a major cancer center to talk with a leading edge specialist.

Above all remember: if you are diagnosed with Low-Risk disease you do not require any immediate radical treatment. You can be safely monitored with “Active Surveillance.” When you are watched closely, treatment can be safely delayed until there is some sign of progression.

Even then, the cancer will still be manageable. Multiple studies clearly show that survival rates of men on Active Surveillance match those of men getting immediate surgery. Also, be particularly careful if you are in your 70s or 80s.  Men in this age group are rarely at risk of disease that will be clinically significant in their lifetime, and these men have the highest incidence of overtreatment. As you start out on your prostate cancer journey, be very aware that overtreatment of this disease is rampant, and do not become a needless victim of unnecessary treatment.