Making Friends with Your PSA

BY RALPH BLUM

It’s a simple enough blood test. So who’s afraid of a PSA? The straight answer? Every guy who’s ever been told his PSA was elevated for his age, and that he needs to have a biopsy. Because from that point on, things can happen fast. It’s the prostate cancer version of the old Tinker-to-Evers-to-Chance double play: PSA Test to Biopsy to Surgery.

PSA is an acronym for prostate-specific antigen, a protein produced by normal prostate cells. Cancer cells, however, produce more PSA per unit volume than benign cells. Since 1986, PSA testing, although not perfect, has served as the gold standard for early diagnosis and—the area of most controversy—screening for prostate cancer.

While with the majority of younger men, early diagnosis far too often leads to unnecessary treatment and anxiety, urologists are justifiably concerned that, without PSA testing, they will miss diagnosing the less-common high-grade form. So, when in doubt, test.

So, I’m talking primarily to those of you with low-grade tumors, conditions that qualify as “chronic” and might better not even be called “cancer.” That doesn’t mean that being newly diagnosed with prostate cancer is any less of a shock. But there are things you can do to reduce the anxiety.

Bottom line, after all the millions spent and all the years of research, we still don’t have a foolproof diagnostic test for prostate cancer. So don’t panic if you get a high PSA reading. Here are some factors that can distort PSA test results in ways that don’t necessarily indicate cancer:

BPH: Benign prostatic hyperplasia, prostate enlargement caused by age or infection, can produce elevations in PSA not indicative of cancer. Check it out.

Infection: Consider the possibility of infection. When my PSA spiked unaccountably from 5 to 17, my wife, Jeanne, who practices Traditional Oriental Medicine, put me on a course of Cipro, and my PSA plummeted back to 6.5 within two weeks.

The 48 Hour Rule: Strenuous exercise, heavy lifting, sexual activity, even bicycle riding before a PSA test are all considered to negatively effect the result. So don’t do any of it before your PSA test.

Inconsistent Lab Work: Standardization between assays and labs is still lacking, making comparisons between PSA tests from different labs are unreliable. Make certain your urologist uses the same lab every time.

Then, there are those of you for whom PSA testing is a higher priority:

Family history: If you have a family history of prostate cancer, it’s advisable to begin PSA testing at 40 and repeat the test at six-month intervals.

African Americans: All African-Americans are advised to begin tests by age 40 regardless. The death rate from undiagnosed prostate cancer for African-Americans is currently twice that of Caucasian men. Partly for genetic reasons, partly from refusal to submit to the DRE, the finger-up-the-butt trick the rest of us, so to speak, take in our stride. Trust me, it’s over before you know it. 

Men Over 75: Nowadays, men over 75 are apt to be spared testing entirely. So avoid the anxiety, and have a good time? On the other hand, you might just go for the PSA test, and take the prostate cancer alert as a wake up call to get yourself a checkup.How long since your last physical, dude?

Finally, remember that the big decisions are all yours to make. So never hesitate to go for a second opinion—or a third. And if you don’t like the test results, get another PSA test done by a different lab. Or find a different urologist.

The best clinicians do not mindlessly screen all of their male patients. They decide which men should be tested based on age, symptoms, family history, expected longevity, general medical condition, physical examination findings, and—a significant factor—the patient's own request for the test. The goal of early detection remains to identify patients who have clinically significant cancers at a time when treatment is most likely to be effective.  

And here’s the really good news: 28 out of 30 men reading this blog, who do have prostate cancer, will die with it, not of it.  Regardless of its shortcomings, the PSA is still the most useful test that is widely available.

So if you’ve been avoiding it, have a PSA test done this week. And while you wait for results, instead of fretting, call the golf pro and get yourself a tee time for Saturday.

Prostate Imaging with Color Doppler Ultrasound

BY MARK SCHOLZ, MD

Prostate cancer is the most common form of cancer in men. While some types are life-threatening others are not.  Recently the media have been reporting on serious concerns that have surfaced about men with the benign forms of the disease undergoing unnecessary radical treatment.  PSA screening has been receiving most of the blame, but the real problem is over reliance on random needle biopsies performed by an aggressive medical community made up of surgeons.

Significance of an Elevated PSA
An elevated PSA can occur as a result of any physical alteration of the environment in the prostate-- recent sexual activity, infection, cancer, and gland enlargement (BPH). A modest elevation of PSA is medically nonspecific. As one man explained, “Think of the Check Engine light on the dashboard of your car. It’s significant if it is ON, but further specifics need to be determined before taking any action.”

Time for a Random Biopsy?
PSA elevation typically triggers an immediate 12-core random biopsy. Presently, over a million men are undergoing biopsy every year at a cost of billions of dollars. Unfortunately, low grade prostate cancer is so prevalent in the general male population that a random biopsy will find prostate cancer 20% of the time, even when PSA is normal. Obviously a great preponderance of all this “cancer” must be harmless. After all, historical death rates from prostate cancer before 1987, when PSA screening first became available, were only 3%.

Damn the Possible Side Effects, Treat it Anyway
Cancer is a frightening word. To many, it portends death. Therefore it’s hardly surprising that both doctors and patients swing into immediate action when the biopsy shows CANCER. Amending and tempering words such as “low grade” or “microscopic” seem to produce no soothing affect whatsoever on the instinctual fears generated by this venomous diagnosis.   Despite the universal agreement of hundreds of prostate experts at a consensus conference back in 2007 which concluded that low-grade prostate cancer can be safely monitored, 85% of all men diagnosed still throw caution to the wind and get treatment anyway.

Imaging is “Blind” to Small Low-Grade Cancers
Back when doctors regarded all types of prostate cancer as universally dangerous, prostate imaging, which is prone to miss small, low-grade lesions, was deemed inadequate. However, with our modern perspective, knowing that only larger, higher-grade lesions are clinically relevant, imaging makes perfect sense. There are two types of prostate imaging: High-resolution Color Doppler Ultrasound, which is the subject of this blog, and multiparametric 3-Tesla MRI which was the subject of my last blog.

Color Doppler Ultrasound Imaging
It’s no longer appropriate to needle the prostate multiple times with the outdated belief that it’s essential to diagnose every tiny prostate cancer.  Practically speaking, only prostate cancers large enough to be “seen” (with imaging) need to be considered. Color Doppler Ultrasound scanning of the prostate is performed by a physician in the doctor’s office. It is actually two scans in one: Standard “Grey Scale” imaging and Color Doppler imaging to detect areas of increased blood flow.  First, ultrasound enables accurate measurement of the gland size. Second, from a cancer point of view, imaging with Color Doppler has three possible outcomes:   

A)   Completely clear

B)   An overtly suspicious lesion is detected

C)   Ambiguous lesion(s) are detected

Targeted Rather than Random Biopsies
When an overtly suspicious lesion is detected, a targeted biopsy (a limited number of cores aimed directly at the lesion) is typically recommended. Lesions that are biopsy-negative or show low-grade cancer are simply monitored.  When high-grade disease is diagnosed, a process of further staging followed by pertinent counseling about the different treatment options is initiated.

When to Biopsy Ambiguous Lesions
Expert judgment, with appropriate attention to the individual patient characteristics, comes into play during a discussion between patient and doctor about whether or not to do a targeted biopsy. Color Doppler “sees” all sorts of things including scar tissue, areas of active prostatitis, and nodular areas from BPH. A follow-up scan in six months to see if a lesion shows further growth may be preferred to immediate biopsy.  Lesion characteristics that raise greatest concern tend to be located in the peripheral zone of the prostate, and include lesions over a centimeter, lesions that bulge the prostate capsule and lesions that have increased blood flow.  Targeted biopsy is advised more frequently in men who are younger, are more anxious about missing cancer, and in men with PSA levels higher than they “should be” relative to the size of their prostate. 

“Cross Checking” Ambiguous Lesions with Multiparametric MRI
Color Doppler Ultrasound and Multiparametric MRI (MP-MRI) are complementary. In our experience the imaging findings match. However in a minority of cases one imaging modality will illuminate a specific lesion substantially more clearly. Therefore, in ambiguous cases, a combination of both modalities increases confidence that high-grade cancer isn’t being overlooked. Doing a second imaging procedure with MP-MRI is often preferable to doing an immediate biopsy.  If subsequently a targeted biopsy is deemed necessary, the additional imaging information obtained from MP-MRI may further increase the accuracy of the targeted biopsy.

Color Doppler for Monitoring Low-Grade Cancer
These days’ experts advise men with low-grade prostate cancer to forgo surgery or radiation and monitor their condition with Active Surveillance. The most common protocol used presently is regular PSA testing and periodic random biopsy. However, multiple random biopsies are associated with discomfort and progressive risk of serious infections and impotence.  Sequential monitoring of small lesions with Color Doppler to determine if they are growing or stable is a far more logical approach than subjecting men to repeated biopsies.

Final Thoughts
Men with elevated PSA, who initially undergo a Color Doppler, rather than random biopsy, are often spared biopsy altogether if their scan is clear.  Men who do require biopsy will need far fewer cores taken because the biopsy is targeted to a specific lesion within the gland. Men on Active Surveillance and men who have undergone previous treatment with surgery, radiation, cryotherapy, HIFU or hormone blockade are also candidates for Color Doppler Ultrasound to determine how well they are responding to treatment. 

A Prostate Biopsy Can be Dangerous

BY MARK SCHOLZ, MD

Last August, I railed against too many biopsies. However, my experience at a recent prostate cancer meeting prompted me to revisit the topic for today’s blog.  There is now general agreement among experts that prostate cancer is over-diagnosed.  I believe this results from the excessive use of random prostate biopsy and, all too often, leads to radical over-treatment.

More than a million men in the United States have prostate tissue extracted by transrectal needle biopsy every year. Of all those biopsied, one-fourth, about 240,000 men, are diagnosed with prostate cancer. Of these 240,000, between one-third and one-half—that is, from 80,000 to 120,000—are diagnosed with a harmless condition destined to remain dormant for life. And yet, despite the innocuous nature of low-grade prostate cancer, the great majority of these unfortunate men still undergo radical treatment with decidedly negative impact on their quality of life.

The unwillingness of surgeons and radiation therapists to withhold treatment for low-grade prostate cancer is not entirely surprising given that doctors are specifically trained to treat cancer.  Understandably, patient enthusiasm for treatment is also a major contributing factor, considering how dangerous it would be to withhold treatment of most any other type of cancer.

The overtreatment of prostate cancer is giving experts sufficient concern that editorials are appearing in prestigious scientific journals, such at the Journal of Clinical Oncology and Lancet Oncology, discussing the possibility of renaming low-grade prostate cancer something besides “cancer.” Everyone seems to agree that it’s unreasonable to name a condition cancer when we know this low-grade form doesn’t usually metastasize.

Given these daunting issues, I was interested to survey a group of twenty male experts at a prostate cancer meeting last month about their attitudes toward biopsy.  Because the average age of the group was around sixty, everyone in the group readily agreed that if all of us underwent a standard random biopsy at least five would be diagnosed with prostate cancer. With such a high statistical risk of finding cancer, I then asked by a show of hands if anyone was interested in having a biopsy.

While an unnecessary cancer diagnosis is one risk of biopsy, there is one other significant risk: the possibility of toxic effects of biopsy itself.  The Journal of Urology this month reports that with prostate biopsy the rate of infections serious enough to require hospitalization has quadrupled to approximately one in fifty. One out every twenty of these infected men admitted to the hospital actually dies—making the risk of death from biopsy is one in a thousand.

Not a single doctor raised his hand.

Fortunately there is an excellent alternative to random biopsy.  Modern prostate imaging with 3-Tesla MRI or color Doppler ultrasound, is just as accurate for detecting high-grade disease. When an abnormality is detected through imaging, it can be targeted with just one or two biopsy cores instead of randomly shooting a dozen cores throughout the gland. And yet, despite the obvious advantages of imaging and targeted biopsy, practically all biopsies done in the United States are being performed randomly. 

Sadly, the general public—including most primary care physicians and even perhaps the majority of urologists and radiation oncologists—remains uninformed about the advantages of modern imaging technology. For more information about biopsy and Imaging Technology see my March 27, 2012 blog, Biopsy, Biopsy Everywhere: http://prostatesnatchers.blogspot.com/2012/03/biopsy-biopsy-everywhere.html

The First Decision: Screening for Prostate Cancer with PSA

BY MARK SCHOLZ

Prostate cancer is highly curable when it is identified at an early stage. The PSA blood test, although not foolproof, improves the chance of arresting cancer while it’s still contained within the prostate. Detecting prostate cancer early gives men the power to choose a variety of treatment alternatives.

Surprisingly there are arguments against PSA testing.  Since some types of prostate cancer are low-grade, and therefore slow growing, diagnosing them, especially in older men, may only cause unnecessary fear and anxiety. Even more disturbing, men with this low-grade, non-aggressive type may be encouraged to undergo unnecessary treatment that in many cases leads to urinary incontinence or impotence.

PSA elevations also can occur from non-cancerous conditions. Prostate infections, prostate enlargement and even recent sexual activity may cause the PSA to rise temporarily.  If none of these reasons can account for an abnormally elevated PSA level, an assortment of scans, blood and urine tests may be required to ferret out what is actually causing the elevation.

So we have a dilemma. Many men are given a PSA blood test without first being educated about its limitations. Advance discussions about the implications of an abnormal PSA, and prostate cancer diagnosis almost never occur. This is no small issue. Even though low-grade prostate cancer is incredibly common, many doctors are still unaware that recent studies show that low-grade prostate cancer can safely be monitored. Instead, when the diagnosis is made, most men are carted off to have radical surgery.

Despite all these daunting issues, I still believe that PSA screening is appropriate so long as men are informed about its limitations, and so long as the doctors who administer the test are well versed in the latest studies. In my next blog I will be addressing an even bigger question—whether to have a prostate biopsy when an elevated PSA occurs.