(Information on understanding your prostate, an excerpt from The Life of Men by Jeffrey Rabuffo, MD, chapter titled The Doctor Is In)
As noted above, PSA, or prostate specific antigens, are produced in the outer or peripheral zone of the prostate gland. In guys, this antigen circulates throughout our bloodstream. The acronym PSA is often used to mean the test for detecting blood levels of this chemical compound. It is not an expensive test. The significance of that fact will become apparent shortly, as it is relevant to the controversy surrounding administration.
The PSA is a simple blood test that can be given at any time of the day, and does not require fasting. In my opinion it should be part of one’s annual physical exam—starting at the age of fifty-five, or earlier if the patient has a family or ethnic history of prostate cancer. It is unclear if family history is important because of common genetics or because of similar familial behaviors, but either way having a first-degree relative (brother, father) with PCa correlates to a risk rate 2.5 to 7.7 times higher than having no affected relatives. Risk declines if the affected relative is second-degree (uncle, grandfather), and more so if the relative is more distant. If the family member contracted the disease before age 50, one’s risk rate also increases. Some guidelines require the cessation of the test at age 70, citing life expectancy averages versus the average time for the disease to become lethal. That is the equation responsible for the idea that men die with the disease, not from it.
The purpose of the PSA test is to allow your physician to detect prostate cancer in its earliest stage, so it can be treated and cured. This method of testing has been available for about twenty years. It is an effective diagnostic tool, yet some physicians (and insurance companies and government bureaucrats) continue to debate its value. The American Board of Urology and the American Board of Oncology both recommend it; yet the American Academy of Family Practice feels the test leads to unnecessary surgeries and other treatments, and does not recommend it.
Let’s put this in perspective. The PSA—the actual test not including the office visit, blood draw labor, facilities overhead, transportation of blood to the lab, etc.—costs approximately $10. Yep, ten bucks. That’s it. We are not talking here about something that is going to break an insurance company or a government health program. So that is not a concern—unless someone is worried that they may have to pay for treatment if disease is found! With people frequently changing insurance providers, delaying detection may be financially beneficial by kicking the can down the road until it is someone else’s problem. More on the economics of this below.
The PSA test is simply an indicator that shows if there is an abnormality in the prostate. If the antigen level in the blood is elevated, it can be due to one of three things: a benign enlargement of the prostate, an acute infection of the gland, or prostate cancer. At this point a frank discussion with your physician is necessary. Depending on the degree of elevation and on family history one may choose to repeat the PSA. Repeated high or rising levels indicate a prostate biopsy should be ordered to determine the condition that exists.
The biopsy is a trans-rectal procedure, which is moderately uncomfortable but not particularly painful. I’ve heard patients describe it as someone pushing a staple gun up your ass and shooting a staple into the prostate. To one not seeing the tool, the sound may be similar. There are no staples, but a thin biopsy needle does fire forward and retract seemingly in an instant. [As an aside, women going through breast biopsies don’t have it much better. Some describe it as lying face down on a torture-table with a hole in it that has a vice that squeezes the breast to prepare it for the biopsy gun.]
Most biopsies come back negative; about 30% come back positive. By comparison, 17% of breast biopsies are positive. These rates factor into the controversy, but realize that when a woman receives a negative result, her reaction, and the reaction of those involved with her, be they family or the sisterhood, tends to be, “Phew! Thank God.” When a guy receives a negative result from a prostate biopsy, the common reaction from others is, “See! That was unnecessary.”
If the biopsy comes back positive, the treatment options depend upon the grade of the cancer, and the age and overall medical condition of the patient. A low-grade prostate cancer can be watched. For this we use the term active surveillance (AS). AS requires semiannual PSA testing, visits to the urologist, and repeat biopsies—usually every other year. Approximately 85% of patients with low-grade cancer do well; 15% do not. That’s the reason for the close observation. Keep this 15% in mind. If the grade of the prostate cancer is moderate or high, then treatment options might include radiation in the form of radioactive seeds (Intensit-modulated radiation therapy or IMRT), hormone therapy, radical prostatectomy (usually preformed robotically), or some combination of all three.
The use of the PSA test does require discrimination. The treating physician must determine, before ordering the test, if the individual will benefit from the results. If a patient is elderly or suffers from other comorbidities, the test may not be appropriate. The use of the test should be discussed with the patient and his family.
Saying that, I strongly disagree with critics who state that doctors would need to screen 1,000 men to save one life; and use that statement to deny testing. First of all, even if that were true, so what? We put seatbelts in millions of cars at considerably higher cost to save less than one life per thousand. That really is, or should be, beside the point.
Left undetected, prostate cancer advances and can cause great pain and suffering. I have seen this too often in my practice. PCa is not a harmless disease. As noted earlier, 30,000 men die each year from PCa; and there are nearly 300,000 new cases annually. Critics of PSA testing ignore immutable facts. Since the advent of PSA testing the death rate from prostate cancer has dropped 30% to 40%; and the incidence of metastatic prostate cancer as the initial presenting symptoms has decreased by nearly 80%! Why would we not want to have, and use, this valuable diagnostic tool? Critics also cite the downside of treatment, which can include loss of urinary control and erectile dysfunction. Really! These are problems we can deal with—if you’re alive!
New advances in biomarker testing are just now coming into more common use. We’ll talk about them below.
[End of Excerpt]
Jeffrey Rabuffo, MD
Dr. Jeff has a weekly, half hour, live radio show on WLIS/WMRD, 1150AM (Old Saybrook, CT), which can be streamed live or on demand via http://wliswmrd.net. The show airs Mondays at 11AM with a replay on Thursdays at 11AM.
You can also order a copy of Dr. Jeff’s book, The Life of Men, available in a 2nd edition paperback on Amazon at this link http://amzn.to/2oICjjx
Dr. Jeff is also available to speak at your group, club, or organization.
He can be reached via email: firstname.lastname@example.org