Chad Bryan, a physician assistant for Advanced Urology Institute, discusses the importance of understanding prostate health in men. He highlights how society is becoming more educated about the issue through direct advertising from pharmaceutical companies.
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Prostate-specific antigen (PSA) is a protein produced by cells of the prostate gland. It is synthesized by both normal and malignant cells and released in blood. The PSA test measures the quantity of this protein in a blood sample, which is then reported in nanograms of PSA per milliliter (ng/mL) of blood. A PSA level of 4.0 ng/mL and below is often considered normal.
The blood PSA level is typically elevated in men with prostate cancer. Therefore, the test is usually ordered in conjunction with the digital rectal exam (DRE) to screen men that are asymptomatic for prostate cancer. It is also recommended for monitoring the progression of prostate cancer in men already diagnosed with the disease, and to test men with prostate symptoms to find out the nature of their problem.
Apart from prostate cancer, there are a number of conditions that may increase the PSA level. For instance, PSA is elevated with age, usually due to enlargement of prostate tissue over the years. Prostatitis (inflammation of the prostate), which is a condition common in men under 50 years due to bacterial infection, tends to result in increased PSA level. Other conditions that lead to increased PSA level include benign prostatic hyperplasia (BPH), urinary tract infections, prostate injury, recent ejaculation, high parathyroid hormone, and surgical procedures.
Although a PSA level of 4.0 ng/mL or below is often considered normal, the level of the protein can vary over time in the blood of the same man, making what is usually taken as the normal range less accurate. In fact, studies have indicated that some men with PSA level below 4.0 ng/mL have prostate cancer while many men with levels above 4.0 ng/mL have been found free of the cancer.
Besides, due to the various factors that may cause a fluctuation of PSA level, such as age, prostatitis, BPH, and urinary tract infections, having a fixed normal range for all men is unreliable in some cases. Equally, since PSA test results vary from one laboratory to another and because drugs like Dutasteride (Avodart) and Finasteride (Proscar) that are used to treat BPH tend to lower PSA level, a single elevated PSA may not be very helpful.
Therefore, to use an elevated PSA as the basis for ordering a prostate biopsy to ascertain whether prostate cancer is present, it is now recommended that the level of PSA is monitored over time. A continuous trend of increasing PSA in blood over a prolonged period of time, together with a suspicious lump detected via the DRE, is a more accurate basis for suspecting prostate cancer and ordering for a prostate biopsy.
For men without symptoms of prostate cancer, an elevated PSA level may be followed by a repeat PSA test to confirm the original finding. And if the PSA level is still high, the urologist may recommend that more PSA tests and digital rectal exams be done at regular intervals so that any changes can be monitored over time. If the PSA level continues to rise or if a suspicious lump is found during a digital rectal exam, the doctor may now order for confirmatory tests.
For example, a urine test may be requested to establish if the rising PSA level is due to a urinary tract infection. Likewise, imaging tests like cystoscopy, x-rays or transrectal ultrasound may help to show the size and nature of any lump.
And if the tests show there could be prostate cancer, the urologist will recommend a prostate biopsy. Multiple samples of prostate tissue are collected by inserting hollow needles into the prostate through the wall of the rectum. The samples are examined by a pathologist to confirm whether the cells are cancerous or not.
After treatment for prostate cancer, the urologist will want to continue to monitor the PSA level to establish whether the disease is recurring or not. An elevated PSA level after treatment is usually the first sign that the cancer is recurring. In fact, an elevated PSA after treatment often happens many months or years before the signs and symptoms of prostate cancer recurrence show.
A single elevated PSA test isn’t enough to conclude that the cancer has recurred. So the urologist will recommend that the test be repeated a number of times, and be done together with other tests, to check for evidence of prostate cancer recurrence. Repeated PSA tests help the doctor to establish a trend over time instead of relying on a single elevated PSA level.
At Advanced Urology Institute, we are committed to the highest standards of urologic care. We make sure to use the right diagnostic and treatment tests, techniques and procedures to deliver the best possible outcomes for our patients. That is why when it comes to the PSA test, we do not rely on a single elevated result to draw conclusions about your prostate health.
It is our practice to monitor elevated PSA for a prolonged period of time and to use the test alongside risks factors (age and family history) and other tests like the digital rectal exam, before we can make conclusions regarding your prostate health. We believe that an elevated PSA level is a valuable tool for early detection of prostate cancer and for successful treatment of the condition if the test is used properly. For more information on prostate cancer diagnosis and treatment, visit the site “Advanced Urology Institute.”
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My name is Brian Hale, I’m a board certified urologist working with Advanced Urology Institute.
Certainly any man over the age of 50 should be screened for prostate cancer, it is the #2 cause of cancer death in men. There’s a lot of controversy about the PSA because of its lack of specificity: a lot of men who have elevated PSA do not have prostate cancer, but unfortunately we don’t have a better task. We have a rectal exam but that misses more cancer than the PSA, so to stop screening for prostate cancer was a mistake and they actually only reversed that recommendation on screening for prostate cancer based on what was happening. We were seeing a lot of men with Metastatic disease.
I started private practice in 1995, and from 1995 until the last five (5) years or so, I didn’t have any metastatic prostate cancer patients in my practice, and now I have a lot, and a lot of it was from a lack of screening. I have patients that were trying to do everything right: watching their weight, exercising and they stopped screening for prostate cancer because of the recommendations. They would have symptoms like blockage from their prostate or blood in their urine. We would check a PSA and we would find it to be extremely high and later find they have metastatic disease because of lack of screening. I have several patients I know on the top of my head that have had that problem, unfortunately. So I would definitely recommend that they continue screening for prostate cancer. [While] it is true, we need a better test than PSA, but just because we don’t have a better test doesn’t mean we should stop screening and I think the government is coming back around to that because the treatment of metastatic prostate cancer is a lot more expensive than the treatment of early prostate cancer.
About 70 percent of men diagnosed with prostate cancer through PSA screening have low-risk, low-grade disease. Unfortunately, over 90 percent of these men are placed under aggressive treatment soon after diagnosis when in real sense up to 60 percent of them may not need treatment, even in the long-term. Why does this happen? The common screening tests are not able to distinguish between men with prostate cancer that requires treatment and those with clinically insignificant disease. In fact, the PSA test, which is the most frequently used screening test, gives up to 12.5 percent false positive results.
There have been growing concerns over the increased number of prostate cancer cases diagnosed and treated following PSA testing. For instance, overdiagnosis through PSA tests has resulted in more men undergoing biopsy, which comes with adverse effects such as pain, acute urinary retention and urosepsis. Likewise, for men placed immediately under aggressive treatment, there are concerns over psychological distress and adverse effects to treatment such as urinary incontinence, bowel dysfunction and erectile dysfunction, among others, which are typically longstanding and life-altering. So because of the quality-of-life issues and financial costs, attention is shifting to ways of minimizing the harm caused by PSA screening, particularly ways of mitigating the conversion of overdiagnosis to overtreatment.
At Advanced Urology Institute, we have designed our screening, diagnosis and treatment processes for prostate cancer to respond to these growing concerns and minimize both overdiagnosis and overtreatment. For instance, we have included a candid patient-urologist discussion of both the PSA and digital rectal exam to make sure our patients are properly informed of their pros and cons. We also perform these screening tests in an individualized manner, based on each patient’s risk factors. As a baseline, we allow men to take their first PSA screening only when in their 40s. This enables us to develop the right screening protocol for each patient.
If a man’s PSA is low during the first test, we generally consider him to have a low lifetime risk of the disease and may not recommend frequent PSA measurements for him. And if we find PSA < 2 for a man in his 60s, we consider him to have a negligible chance of dying from the cancer and recommend that he not undergo any further PSA screening. It’s only for men with higher risk, such as those who have had a first-degree relative with the cancer — which doubles their risk of developing prostate cancer — that we may recommend more frequent screening.
Previously, any man with a PSA result that was worrisome, such as one showing a rise over time or has an absolute high value, would automatically be a candidate for biopsy. At Advanced Urology Institute, we have changed this and now may perform other tests before we can recommend a biopsy. For instance, we can use a second test called PCA3 to define a man’s risk level and assess whether or not a biopsy is necessary for him. The PCA3 is a more specific marker for prostate cancer than the PSA and it can be measured in urine, usually after a DRE. Similarly, we can assess the aggressiveness of a tumor through genomic testing and use the results to determine whether immediate treatment or active surveillance is appropriate. So we use such tests to reduce the harm that our patients may suffer from biopsies done due to PSA-based overdiagnosis.
To further reduce the chances of treating indolent prostate cancer, we use a combination of PSA and biopsy to assess and classify patients according to degree of aggressiveness of their disease. At AUI, we are committed to minimizing unnecessary, worthless or even harmful treatment after cancer diagnosis. Our most preferred management strategy, particularly for men diagnosed with localized, low-risk prostate cancer, is active surveillance as opposed to immediate treatment. It involves following men with low-grade, low-risk cancer closely and only providing treatment for tumors that exhibit aggressive behavior or are spreading to other areas of the body. Through careful observation, we have realized that a majority of men do not need treatment and therefore are spared the unnecessary aggressive interventions.
During active surveillance, we usually recommend serial PSA testing and biopsy to help monitor the behavior of the tumor. Before we put patients on active surveillance, we inform them that there is a possibility that the cancer may spread to keep them psychologically prepared just in case we detect progress. We also make them aware of the cancer-specific mortality with and without treatment, which is usually less than 10 percent without treatment and reduced by about 50 percent with radiation or surgery. We also inform them of the pros and cons of active surveillance and provide them with all the information they need to make personal treatment decisions.
Our approach is quite different for patients with high-risk prostate cancer. For them, we usually begin curative treatment as soon as possible, using the tools available to deliver safe, timely and effective treatment. The most common treatments for high-grade, high-risk prostate cancer are radiotherapy, high-intensity frequency ultrasound and robotic prostatectomy. Want to know more about prostate cancer screening, diagnosis and treatment? Visit the “Advanced Urology Institute” site.
