7 Reasons PSA Testing Still Matters

29000 Men Comment
As I have stated before in this blog, it is my fervent belief that PSA testing currently is the only effective means of preventing prostate cancer deaths. It’s not knowing you have prostate cancer that causes over treatment, it is faulty patient decisions. I say patient decisions because ultimately each of us is responsible for the treatment we undergo. We cannot, and should not, place that responsibility on the medical community.

If you are interested in a balanced view of the current PSA testing controversy, read the following article by Dr. Ford Vox on his blog at

Begin Dr. Vox’s Blog Post:

The PSA Test: 7 Reasons It Still Matters
November 13, 2009 03:55 PM ET | Ford Vox | Permanent Link | Print

The U.S. Preventive Services Task Force asked doctors last year to stop checking PSA levels in elderly men—the very men who are most likely to have prostate cancer. By age 75, the officials reasoned, doctors are more likely to keep tinkering with their patients until they die of treatment side effects or something other than prostate cancer altogether. This spring, the New England Journal of Medicine published two long-term studies that questioned whether knowing a man's PSA level actually helps men survive. Healthcare commentators say that PSAs set off a cascade of overtreatment, endangering patients and tolerating wasteful medicine, and that patients should be wary.

You might expect that the surgical specialists at the center of prostate cancer treatment would have reined in their PSA testing, but they haven't. The American Urological Association actually lowered its recommendation for the age at which doctors should start offering patients the PSA test from 50 to 40. It was the first revision of the guidelines in nearly a decade. The next one, says Kirsten Greene, a urologist who worked on the committee, should take just a year, in light of the accelerating data and heightened public debate.

"The key change is how we react to abnormal tests and to a cancer diagnosis, which is generally less aggressively for some men than in the past," says Gerald Andriole, chief of urologic surgery at Barnes-Jewish Hospital/Washington University School of Medicine in St. Louis. Andriole says that men shouldn't be afraid to get diagnosed; good urologists avoid overtreating less-dangerous cancers. Active surveillance or targeted attacks on very small tumors that spare healthy prostate tissue are both popular options.

From the latest research, here are seven reasons why urologists are encouraging men of any age who expect to live at least another 10 years to think hard about getting a PSA test, even if they have to pay out of pocket:

1. Keeping tabs on PSA saves lives. Many urologists flat out reject a large study published in the New England Journal of Medicine earlier this year that found men who got the PSA test did worse than men who didn't. The dissenters say the results weren't trustworthy—many of the men who weren't supposed to get tested actually did, thanks to their proactive primary-care docs. Another recent large NEJM study found that nine years after entering the study, men who got regular PSA screening were 20 percent less likely to die of prostate cancer. One model suggests the PSA test has contributed to much of the 30 percent decline in prostate cancer deaths seen in recent decades.

2. There's no magic PSA number. In the urologists' latest recommendations, it is clear that there's no one-size-fits-all age at which to be tested or bad PSA number. For many years, a particular reading of 4 or above was a battle cry that called for a biopsy or aggressive treatment. In reality, any reading is suspect. Without knowing much more about him, studies give a middle-aged man a 10 percent chance of having visible cancer on biopsy even if his PSA level is zero. Today, doctors consider a single PSA number in the context of your specific health background, race, and family history (it may also help diagnose benign enlargement or an infection), and then suggest when to be tested next. If you do get a biopsy, the criteria for serious concern are stricter, and there are more conservative treatment options.

3. Velocity matters. Your first PSA test is neither your last nor your most important. Depending on your age and your current PSA number, the question is how much, and how fast, subsequent test numbers increase. Researchers are busy determining just how much velocity is normal. (Some researchers say a speed bump of more than 0.25 in one year for a 40-year-old man should prompt concern.) Every man generates a history of data points his doctors can interpret in light of the research.

4. There ' s more than one kind of PSA to measure . Enlarged but noncancerous prostates usually release "free" PSA that circulates through the body, while PSA produced by cancer cells tends to attach itself to proteins in your blood. By considering the ratio of the types of PSA, as is done by looking at the ratio of bad to good cholesterol for heart disease, doctors can offer you better advice about your risk and what you should do next.

5. The younger you are, the more meaningful the PSA test. Older prostates tend to get bigger and put out more PSA, complicating interpretation. Higher PSA levels at a younger age are an indicator of elevated risk and call for closer monitoring of factors like your PSA velocity. At the same time, prostate cancer therapies are most effective and sparing of function when the cancer is at an early stage.

6. PSA numbers reveal your prognosis and are critical in follow-up. If you do develop a serious form of prostate cancer that requires aggressive treatment, your PSA levels prior to treatment will help your medical team determine the risk of recurrence. It's one factor among many others, such as how the tumor looked under the microscope after surgery, but the latest studies show it's of real value. After surgery to remove the prostate, the PSA test is even more critical: Detection of extremely minute levels can signal cancer recurrence. The earlier doctors know the cancer is back, the earlier patients can decide about secondary treatments like radiation and hormonal therapy.

7. For now, PSA is the best we've got. Scientists are looking hard for a better "biomarker" than the PSA, ideally one that doesn't require so much deliberation. Candidates are surfacing, but they require more proof. Physical measures like the prostate's size can be misleading, as Mayo Clinic researchers reminded us this week. Studies show that a digital rectal exam plus a PSA test is the surest way to pick up prostate cancer. But if you've got to pick only one test, PSA is still the best.

To PSA or Not to PSA. Is that the Question?

29000 Men Comment
Below is a good description of some of the history of PSA testing and accepted PSA values for specific age ranges. The problem with guidelines is that there are the general rule and don’t cover the statistical outliers. For example, I am an accidental prostate cancer survivor. I was diagnosed at age 57 with a PSA value of 3.2, well within the acceptable range according to the standard. I also had a negative DRE, which was misleading because my tumors were sitting on top of the prostate where they could not be felt. My post treatment diagnosis was Stage 2, with a Gleason Score of 3+3. I am only here writing this blog because my urologist was super diligent and ordered a Free PSA test that came back with a very low ratio (.09; 9%).

Prostate cancer kills almost 29,000 men each year. It is up to each man individually to monitor his PSA, track the changes, and then get the facts. I am not suggesting a rush to treatment, but I do believe it is vitally important for men to know if they have prostate cancer as soon as possible. If you are unlucky and are one of the 1 in 6 men that is diagnosed, the next step is to work with the doctor to determine if you have an aggressive form of the disease.

Please visit us at 29000Men.org and participate in one of our prostate cancer awareness events.

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The PSA Test

Understanding the PSA Test and Results

Prostate Specific Antigen (PSA) is a protein made in the prostate. Normally, very little should be found in the blood. Rising levels of PSA in the blood indicate a problem with the prostate, which could be cancer but could also be an enlarged prostate (BPH).

Annual screening should start at age 45 for the general population, but the right age to start PSA testing depends on your level of risk.

Doctors usually recommend further testing for men with a total PSA level of 2.5 or more nanograms of PSA per milliliter of blood (ng/ml). This cut-off level has been set by the National Comprehensive Cancer Network, a large network of cancer experts who establish industry wide standards.

As PSA levels increase, so do the odds that it’s due to prostate cancer. About 25 percent of men with a PSA level from 4 to 10 have prostate cancer. About 67 percent of men with a PSA above 10 have the disease.

The change in your PSA level over time, PSA velocity, is very important. Even if your PSA is 4.0 ng/ml or below, an increase of 50 percent or more in one year may indicate prostate cancer. If your PSA is above 4.0 ng/ml, an increase of 75 percent or more in one year could indicate an aggressive case of the disease.

There are some factors that you and your doctor may want to consider when it comes to interpreting your score:

* Your age. Doctors may use age-adjusted PSA ranges to account for the natural increase in PSA with age when considering further testing.
* The size of your prostate. PSA Density is a measure that relates your PSA level to the size of your prostate, to account for the increase in PSA caused by prostate enlargement.
* Your weight. Body Mass Index, a measure of obesity, may also be a factor. The relationship between obesity and lower PSA levels may cause doctors to miss early prostate cancer cases in overweight men.
* Ejaculation within 48 hours before taking a PSA test can also cause a higher reading of your PSA level.

Some doctors recommend the following PSA cut-off levels adjusted by age and ethnicity:

Age Caucasian or Hispanic African American Asian

40 to 49 2.5 2.0 2.0

50 to 59 3.5 4.0 3.0

60 to 69 4.5 4.5 4.0

70 to 79 6.5 5.5 5.0

PSA Test Standards

Today, because there are two standards for PSA tests, the same cutoff should not be used across all PSA tests. It is important for you and your physician to know which type of test your clinic’s lab uses and how to correctly interpret the results.

The Hybritech PSA test established 4.0 ng/mL as the cutoff for a normal test. This means men with a score above 4.0 should be referred for further testing, such as a biopsy. Men with a result lower than 4.0 may not be referred for biopsy, depending on their physician’s instructions. As other manufactures developed PSA tests, they aligned their tests to the same standard, which became known as the "Hybritech standard," and other manufacturers used the same recommended cutoff of 4.0.

By the mid-1990s, some researchers began to recognize that test results from different test manufacturers could be slightly different and joined together to create a common calibration standard to better align results from different PSA tests. This standard was accepted by the World Health Organization (WHO) and soon became known in the medical community as the “WHO standard” PSA test. To establish this new standard, a different scientific process to measure molecular weight of PSA was used and found that weight to be 20 percent higher than was used for the Hybritech test. Because of the way this is calculated, a WHO test would show a proportionately lower PSA concentration level than would a Hybritech test for the same sample. As a result, the cutoff point at which men are referred for further testing would more appropriately be set about 20 percent lower than the 4.0 used for the Hybritech test.

To find out which type of test you have received, your physician should contact his or her lab to determine which brand of test was used for their PSA testing and whether it is WHO or Hybritech calibrated.

Types of PSA Tests

Some of the PSA in the blood is bound to enzymes (complexed) while some is freely circulating (free). Unless otherwise noted, the PSA levels generally refer to total PSA (or tPSA), a combination of complexed and free PSA.

Free-PSA or fPSA refers to the percentage of PSA in the blood that is not bound to enzymes. Doctors are now recommending further testing for men with a free-PSA of less than 25 percent. This is a helpful indicator for men who may be uncertain whether to get a biopsy, such as those with PSA levels between 4 and 10, and negative DRE results.

Complexed PSA or cPSA refers to the measure of one type of bound or complexed PSA. This measure is as accurate as total PSA and may be better at ruling out some people from further testing. Cut-off levels are different for cPSA, so make sure you know whether your PSA test is complexed or total. For example, a cPSA level of 2.2 is equivalent to the cut-off level of tPSA at 2.5.

PSA and Recurring Prostate Cancer

The PSA test is also used to detect and monitor recurrence of prostate cancer after initial treatment. PSA levels should drop dramatically after initial treatment. If they rise again, they are a good indicator that the initial treatment did not catch all the cancer cells.

Source: Zero: The Project to End Prostate Cancer http://www.zerocancer.org/site/PageNavigator/PSA_Test

New AUA Prostate Cancer Screening Guidelines

We are happy to provide a link to the AUA's (American Urologic Association) latest prostate cancer screening guidelines. Just visit the site and you can download a copy of their guidelines brochure.

I would like to note that the guidelines recommend an annual PSA for men beginning at 40, along with a DRE (digital rectal exam). Although I am not a physician and do not provide medical advice, I suggest that men have a Free PSA test if their PSA test comes back positive. I say this because in my case my two tumors were located on top of the prostate where they could not be felt by DRE. Fortunately, my urologist requested a Free PSA test (your Free PSA value should be equal to or greater than .25 (25%) of your total PSA, and the tumors were detection prior to metastasis. If your Free PSA/total PSA is less than .25, it is an indication that a tumor may be present and you should consult your physician. If you do not have a physician (and you should!), you can obtain these tests on your own from an independent laboratory.

Remember, it is not the absolute PSA value that matters most, but the change from year-to-year. Should your PSA value change approximately .75 or more from one year to the next, you should see a physician immediately.

Want a little adventure in your life? Join us for all or part of the 2010 Tour de USA for prostate cancer awareness or join us on the Tour de Skyline Drive this August 22-24.