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)?