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.

African-Americans and Prostate Cancer

BY RALPH BLUM

The hard fact is that the death rate from undiagnosed prostate cancer for African-Americans is currently more than twice that for Caucasian men. Although scientists do not yet fully understand why this is so, it is widely believed that genetic differences, lifestyle, reluctance to undergo digital-rectal testing, and nutritional habits all play a role in these statistics. Which is why all African-Americans are urged to begin tests at an earlier age (40) regardless of their health history.

While African-American men are already at an increased risk for prostate cancer, that risk goes up even further if there is a family history of the disease. African-American men, with an immediate family member who had prostate cancer before age 65, have a one-in-three chance of developing the disease. With two family members involved, that risk rises to over 80%. This is why prostate cancer screening at a younger age is vital because by the time that symptoms appear, the cancer is more likely to be at an advanced stage.

The differences in prostate cancer diagnosis and treatment seem to account for a significant portion of the gap in death rates between blacks and whites.  First, black men are less likely than whites to have adequate insurance. Uninsured men have lower rates of screening and are less likely to see a health care professional. These men are more likely to be diagnosed with advanced disease –cancer that has spread outside of the prostate gland. It is worth noting that studies of blacks and whites in the military, where men have equal access to health care services, have shown that this equal access eliminates of most of the death rate gap.

So what can African-American men and their health care professionals do right now?  The advice is the same for black men as for all other men. Focus on early diagnosis through PSA screening.  The controversies about PSA screening are mostly related to over diagnosis of low-grade disease.  Many of these low-grade cancers don’t even need to be treated. They can be safely watched. And that fear can largely be address by evaluating an abnormal PSA finding with a MRI scan rather than a 12-core random biopsy.  Given the extremely high rates of prostate cancer in African-American men, getting a PSA test represents a simple but potentially life-saving act.

Risk

BY RALPH BLUM

Prostate cancer is the most common non-skin cancer in the U.S. affecting one in seven men. It is estimated that there are nearly 3 million American men currently living with prostate cancer and it is still not known what causes the disease. However, here are the main factors that might affect your risk level of risk.

Age
Age is the most significant risk factor. Your risk increases exponentially as you get older. In old age, up to 8 out of 10 men harbor microscopic amounts of the disease in their prostate, live with it, and die of something else. In the opinion of one well-known urologist, “If you are over seventy and you don’t have prostate cancer, chances are you’re a woman.”

A Family History of Cancer
Generally speaking if you have a father or brother who was diagnosed with prostate cancer you are twice as likely to develop the disease compared to the average man, while men with two or more relatives with the disease are nearly four times as likely to be diagnosed. If your relatives were diagnosed before the age of 60, this increases the risk slightly. And the younger the age at diagnosis, the more likely it is you have a faulty gene called BRCA2 in the family. Cutting edge research is ongoing to read and interpret the genetic code of prostate cancer.

Race & Ethnicity
Prostate cancer is more common in black Caribbean and black African men than in white or Asian men. The difference seems to be a mixture of inherited genes and environmental factors. African American men are 56% more likely to develop prostate cancer than Caucasian men, and nearly 2.5 times more likely to die from the disease.

Height & Body Weight
Research has shown that taller men have a higher risk of getting aggressive prostate cancer, or prostate cancer that has spread. And there are a number of studies confirming that men who overeat and who are overweight display increased incidence and aggressiveness of the disease.

IGF-1
Insulin growth factor is involved in the regulation of normal cell growth and death. Some studies have shown that men with a higher level of IGF-1 in the blood have a higher risk of developing prostate cancer. So it is not high blood sugar, but rather the high level of insulin triggered by high blood sugar that stimulates rapid cancer growth.

So what can you do to inhibit prostate cancer growth?  Unfortunately, the days of eating everything you want are over. There has never been a more important time in your life to eat sensibly.  Your diet can no longer be rich in animal fat, processed and fast food and low in fruit and vegetables. We did not evolve and develop to eat this way.  This doesn’t mean you can never have another piece of pizza.  But it does mean that having less than 10% of calories from animal protein can result in a dramatic reduction in cancer risk.

Bottom line, you are not without power in influencing your level prostate cancer risk.

Calling All 40 Year Old Black Men

BY RALPH BLUM

According to the National Cancer Institute, African Americans may have the highest rates of prostate cancer in the world. Furthermore, black men often develop the disease at a younger age than white men, and the cancer is often more aggressive.

Although the National Institute of Health is conducting studies to determine why this is the case, the reason for this disparity between African American and Caucasian men is complex and not yet clear. In part, it may reflect unequal access to quality health care because they tend to be diagnosed at more advanced stages, i.e., they wait till it’s too late.

While all African American men are at significantly higher risk, black men with an immediate family member who had prostate cancer have a one in three chance of developing the disease. The risk rises to 83% when two immediate family members have the disease, and with three family members, the risk mounts to 97%.

So it is absolutely vital to get yourself checked out before symptoms appear that indicate the presence of prostate cancer. Symptoms include: the need to urinate frequently (especially at night); difficult, painful, burning or bloody urination; painful ejaculation; frequent pain or stiffness in the lower back, hips, or upper thighs. Once symptoms appear, it means that the cancer has already reached a more advanced stage and chances of survival are considerably reduced.

In June 2003, Nation of Islam leader, the Honorable Minister Louis Farrakhan, announced the launch of his Prostate Cancer Foundation  (LFPCF). Minister Farrakhan, himself a survivor of prostate cancer, apparently saw the high death rate among African American men diagnosed with the disease as a call to action to the black community, and the strongest persuasion for early screening. “If that is not motivation to save your life,” he said, “then nothing can motivate you.”

Despite the lack of conclusive study results, one thing is certain: early annual screening for prostate cancer is critical for African American men and should begin at age forty to forty-five.

Aside from financial concerns, another factor that deters many African American men from getting regular screening for prostate cancer, is that it involves not only the PSA blood test but also the primitive yet effective doctor-inserting-finger-up-your-anus technique known as the Digital Rectal Exam (DRE) to which black men have a serious aversion. Minister Farrakhan put it rather more delicately: “As men, we are difficult in terms of allowing ourselves to be tested.” And that is a problem.

A word of caution: When I alerted two concerned black friends that “free annual pre-screening, educational materials and medical referrals were available” via the Louis Farrakhan Prostate Cancer Foundation in Chicago, they called the number provided on the LFPCF website, and got a Toyota dealership in Houston. It appears that the website has not been updated since 2003.

When I checked with a black minister who is concerned about prostate cancer in his community, he said, “The Rev. Farrakhan sometimes fails to follow through. Usually, it’s a question of funds. The African American community would welcome hearing words of encouragement from black authority figures like Oprah, Tavis Smiley and Rev. Jesse Jackson.”

Meanwhile, it is left to local groups to motive men to get tested. According to Ron Brewington, Associate Professor of Broadcasting Journalism at Santa Monica College, the Trinity Baptist Church on

Jefferson Boulevard

in Los Angeles does provide screenings. Addressing a group of men at the church recently, Brewington said, “I’d rather have a finger up my butt than have them throw dirt in my face. The fact that you’re here tells me you want to live. I applaud each of you.”

Deaths from prostate cancer in the United States have declined, primarily because more than 90 percent of prostate cancers are diagnosed at an early stage However, African American men are still more than twice as likely as white men to die of the disease largely because they continue to be diagnosed at more advanced stages. So if you are a 40 year old African American man, consider this a three-alarm wake-up call.